Consultation Form

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					                        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:

Name:

Address:




Date of Birth:

Occupation:

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:




Signed:


Please scan the completed form and email to info@mrsfrisbeesallnaturals.co.uk.

				
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posted:9/12/2012
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