Aromatherapy Questionnaire
Your name:
age
your email
Please check the corresponding boxes if you
currently have any of these conditions:
Asthma
 low blood pressure
pregnancy
 high blood pressure
epilepsy
Are you taking any medications?  Please include homeopathic medication.  This is
important because some essential oils (although few) could void the effect of your
treatment or are contraindicated.

If you have any allergies, please list them in the space below.
Please check the boxes below that correspond to the emotional and mental states that
you are seeking to address.
Mental Fatigue
Anxiety or Panic Attacks
Concentration and Focus
Confidence
Depression
Memory
Moodiness & Irritability
Obsessive Compulsive Behavior
Negativity
Relaxation
Stress Disorders
Addiction
Restful Sleep
In the space provided below, please describe how you feel
when you are out of emotional balance. Please mention the
times when you feel out of balance.
Please share any other important information, such as, did you recently give birth?  Have you been ill?
 What are the (if any) factors in your life which may be contributing to how you feel?

Please check the boxes of the types of aromas that you have a tendency to prefer.  If you like them
all, please check all the boxes.

Citrus Smells
Lemon, Orange, Mandarin, Citronella,
Melissa, Petitgrain, Bergamot, Grapefruit, Lime
___________________________________________________________

Woody Smells
Pine, Cedarwood, Rosewood, Sandalwood, Frankincense,   Myrrh
___________________________________________________________

Floral Smells
Rose, Jasmine, Lavender, Chamomile, Geranium, Ylang Ylang, Neroli
___________________________________________________________

Spice Type Smells
Rosemary, Thyme, Sage, Marjoram, Basil, Bay Leaf, Fennel, Parsley, Coriander, Nutmeg,
Cardamom, Lemongrass, Black Pepper, Clove, Cinnamon
___________________________________________________________

Minty Smells
Spearmint, Peppermint
___________________________________________________________

Earthy Smells
Patchouli, Vetivert
___________________________________________________________

Medicinal/Camphorous Smells
Eucalyptus, Tea Tree,Cajuput
___________________________________________________________
Are there any of these types of smells that you
strongly dislike? Please indicate in the box to the
right.
Please check the box of your preferred medium: a body/massage oil or a spritzer?
Body/Massage Oil
 Spritzer
Thank you! You will receive a recommendation at the email
address you provided as soon as possible.

An important property of essential oils is the balancing effect they have on the emotional body,
since an imbalanced state is the surest way of developing disharmony and disease in your life.  
Aromatherapy is a wonderful way to take care of your emotional body.
Aroma Waves currently offers 4 oz of custom made blends for emotional healing.  Blends can be
made to help combat depression, anxiety, stress, and more.  4 oz blends range in price from
$17.00 to $36.00 depending on the oils used.  This includes the cost of the base product and the
essential oils.  You also receive information on how to best use your blend.
You can choose from a body/massage oil or a healing mist as a medium for your blend,
however, sometimes one medium may make more sense to use than the other; I will inform you of
that in your feedback.  Please fill out the following form and submit for a blend recommendation.  
All information submitted is completely confidential
and used only to choose the best blend for you.

DISCLAIMER: The essential oil blends that are recommended are not intended to prescribe in any way and are
not to be used as a substitute for professional help.  (Aromatherapy is almost never used as a sole treatment.)
The intent is to offer my opinion of essential oils and their benefits based on personal use and research through
reputable sources.  If you are suffering from severe mental health issues, please consult a professional.