BESPOKE PRODUCTS CONSULTATION FORM
This consultation form is to make sure you are not contra-indicated to any essential oils used in
your personal blend. Bespoke products are tailored to meet your individual requirements and
essential oils are blended to have a therapeutic effect and not just to fragrance the product.
All information submitted is confidential.
Date of Birth:
Type of product required (facial oil, therapeutic body oil, body lotion, bath salts, bath oil, hand &
body wash, shower gel etc):
Skin type (dry, oily, sensitive, combination, mature):
Skin problems (eczema, psoriasis, rosacea, acne etc):
Skin colour (fair, olive, dark, black):
Allergies (nuts, wheat, hay fever etc):
General state of health:
Muscular & skeletal problems (rheumatism, arthritis, general aches & pains):
Digestive problems (IBS, constipation, bloating, gall bladder, stomach upset):
Blood Pressure (normal/high/low):
Any problems with heart, kidney, liver, circulation, thrombosis, fluid retention?:
Are you taking any medication or having any medical treatment ?
Illness (cancer, hepatitis, deficient immune system etc):
Deficient immune system (prone to coughs, colds, sore throats, chest, regular antibiotic taker):
Do you have epilepsy or diabetes?:
Is your lifestyle busy, stressful, balanced etc?:
Sleep pattern (good, poor, broken or average):
Energy levels (good, poor or average):
Ability to relax (good, poor or average):
Stress level (good, poor or average):
Any comments you may wish to add:
Please scan the completed form and email to firstname.lastname@example.org.