ALEX BATES
Aromatherapy Client Assessment
Marital Status
Single
Married
Divorced
Number of Children
Ages
Activity Level
None
Low
Moderate
High
Energy Level
Low
Moderate
High
Pregnant
Yes
No
Birth Control
Yes
No
High or Low Blood Pressure
Yes
No
Blood Clots
Yes
No
Face Skin Type
Normal
Dry
Oily
Combination
Body Skin Type
Normal
Dry
Oily
Combination
Family History:
Epilepsy
Hepatitis
HIV
TB
Heart Disease
Thyroid
Colon
Lungs
Back and Joint
Stomach Pancreas
Reproductive System
Gallbladder
History of Cancer
Yes
No
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