JGO Client Record Card & \ 3086 HEIGHT S45 STATUS SARI CHILDREN FL DATE OF BIRTH #4 5 93 OCCUPATION BRE MEDICAL HISTORY AND GENERAL INFORMATION @& A $8 HE FO—925085 A OrsnaTions iff CHRONIC oR SERIOUS ILLNESS {EERIE SE ACCIDENTS SE9t MEDICATION ‘TREATMENT TAKEN CURRENTLY/ MEDICATION SIDE EFFECTS IF ANY 6E/H | Doctor name/ Tet BEERES, /REBE SORES | ROTEL AOES) ECZEMA/DERMATITIS/PSORIASIS/ALLERGIES {55 + & YES/NO | MENSTRUAL PROBLEMS (DATE OF LAST PERIOD) IR + 4 BETARICEGEREC yes, give reason why) SOM LMF) HicH on Low sooo pressure em? SiS Yes/No | HEART DISEASE (5% ‘TENSION / HEADACHES HE / BU ‘Yes/No | Diaseric/EriLersy $8504 / #RME SPINAL PROBLEM HEFT Yes/No | Do vou sxencise frHcH)s% DO YOU SLEEP WELL? (RE /BATIE? Yes/No | Diet incLUDING ALCOHOL Bic ELSA Family History REE ‘Do you know of any illness that is contra indicated to this treatment? PRL HT ET? ‘What benefits would you like to receive from this treatment? (AS Gtid MES (G2 {2274807 DATE OF TREATMENT | T am happy to undergo treatment in the knowledge that the therapist is trained and the oe information Ihave given is true and correct SUF S22 MME » AiRURE RI SIGNATURE #% (©IGO Holistic Aromatherapy and Health School Zit aJGO Client Record Card & \ 5d##e-F ESSENTIAL OILS USED SRR ‘* state drops and dilution used Fe RL © give reason for selecting these oils, aOR CARRIER OILS USED eRe Home advice given ERD (NoNEED TO FILL FoR 1 visiT) date of visit ) eam REASON FOR VISIT | GR | CLIENT SIGNATURE BABE AREAS TO BE AVOIDED BERRA A . AREAS TO BE CONCENTRATED BEE MASH 77 (OTHER OBSERVATIONS (ANY IMPROVEMENT IN BETWEEN THE TREATMENTS) KERRIER) (©IGO Holistic Aromatherupy and Health School #@@ 2