芳香疗法案例评估咨询表Aroma Therapy Case Assessment Consultation Form个人资料：PERSONAL INFORMATION姓名：英文名：性别：国籍：Name English Name Sex Nationality出生日期：身高：cm 体重：kgDate of Birth Height Weight婚姻状况：血型：职业：宗教信仰：Marriage Status Blood Group Profession Religion联络电话：（住宅）手机：邮箱：Tel.（Home）Mobile E-mails联络地址：邮编：Address Postal Code健康状况：HEALTH CONDITION您的皮肤是否有过敏史：□否No □是Yes （请说明Description）Do you have any allergies？您是否长期服用某种药物：□否No □是Yes （请说明Description）Are you on prescribed medication？您是否正在接受疾病治疗：□否No □是Yes （请说明Description）Are you currently seeking medical advice？您是否戴有隐形眼镜/助听器：□否No □是Yes（请说明Description）Are you wearing contact lenses / hearing aids?您曾否接受过手术（包括外科整形手术）：□否No □是Yes（请说明Description）Do you have any medical / surgical history (Including plastic surgery ) ?您体内是否有任何金属物件（如心脏起搏器、金属针等）：□否No □是Yes（请说明Description）Do you have any metal implanted in your body ?( such as a pacemaker, pins in bones, or a copper IUD )您曾否怀孕过或正在怀孕：□曾有Had been □没有No□已孕Yes（多少个月How many months ?）Are you or have you been pregnant?您是否有过以下疾患：Please check any health conditions which you have had or are now experiencing：头痛或偏头痛□否No □是Yes （请说明Description ）Headache or Migraine眼疾□否No □是Yes （请说明Description ）Eye Disease鼻敏感或鼻窦炎□否No □是Yes （请说明Description）Sinusitis or Allergic Rhinitis中耳炎□否No □是Yes （请说明Description）Tympanitis喉痛或咽炎□否No □是Yes （请说明Description）Throat ache or Pharyngitis甲状腺□否No □是Yes （请说明Description ）Thyroid gland心脏病□否No □是Yes （请说明Description ）Heart Problems低血糖□否No □是Yes （请说明Description ）Hypoglycemia高血压□否No □是Yes （请说明Description ）High Blood Pressure低血压□否No □是Yes （请说明Description ）Low Blood Pressure糖尿病□否No □是Yes （请说明Description ）Diabetes癫痫症□否No □是Yes （请说明Description ）Epilepsy胃病□否No □是Yes （请说明Description ）Stomach Disease痛症□否No □是Yes （请说明Description ）Painful Areas肝炎□否No □是Yes （请说明Description ）Hepatitis胆结石□否No □是Yes （请说明Description ）Gall-stone肾病□否No □是Yes （请说明Description ）Nephridium Disease内心沁失调□否No □是Yes （请说明Description）Hormonal Problems膀胱炎□否No □是Yes （请说明Description ）Cystitis妇科炎症□否No □是Yes （请说明Description ）Gynecology Inflammation静脉曲张□否No □是Yes （请说明Description ）Varicosity膝关节病症□否No □是Yes （请说明Description）Knee Joint Disease癌症□否No □是Yes （请说明Description ）Cancer肿瘤□否No □是Yes （请说明Description ）Tumor其他□否No □是Yes （请说明Description ）Others生活习惯：LIFESTYLE DETAILS作息时间是否规律：□是Yes □一般Just so so □不规律NoWhether the living schedule is regular？请说明Description ：您的睡眠质量：□好Good □一般Just so so □不太好BadDo you have enough sleep everyday ? 请说明Description ：您的饮食时间是否规律：□是Yes □一般Just so so □不规律NoWhether the diet schedule is regular：请说明Description ：您的饮食营养是否均衡：□是Yes □一般Just so so□不太均衡NoDo you have a balanced diet ? 请说明Description ：您喜好的饮食口味：□甜Sweet □酸Sour □辣Spicy □咸Salty □苦Bitter What is your favorite flavor of food ?□其他Others您喜爱且常喝的饮品：Type and quantities of fluids intake per day□咖啡Coffee （杯cup）□茶Tea（杯cup）□牛奶Milk（杯cup）□水Water（杯cup）□果汁Fruit Juice（杯cup）□酒类Alcohol（杯cup）□豆类饮品（Legume Drinking 杯cup）□其他Others您的运动习惯：□经常Often □偶尔Sometimes □无No （如有：次/星期）Daily Physical exercise How often per week ?您的运动方式：□太极Tai Chi □瑜珈Yoga □气功Chi Gong □冥想/静坐Meditation Type of exercise □跑步Running □散步Walking □登山Climbing □其他Others您是否吸烟：□经常Often □偶尔Sometimes □无No （如有：支/天）Do you smoke ? How many per day ?您现在比较喜欢的颜色：What is your favorite colour ?您的人际关系：Interpersonal Relation家庭关系In Family □紧张Troublesome □一般Soso □良好Fine朋友或同事关系Social Relation□紧张Troublesome □一般Soso □良好Fine您遇事感到焦虑、忧郁吗？□经常Always □偶尔Sometimes □无NoDo you feel anxious or depressed easily?您是否在工作和生活中感觉压力很大：□是Yes □还可以OK □不是NoAre you currently or periodically under a lot of stress ?您的压力指数是（1—10级，10是最高指数）Your stress level is：您的生活满意指数（1—10级，10是最高指数）Your satisfaction level toward life is：治疗师签名客人签名Practitioner’s Signature Client’s Signature导师签名日期Tutor’s Signature Date视觉观察及前期检查Observed Physical Condition in Preparation Period1、身体状况（详述存在的问题describe current problems in detail）：Physical State (Any Problems)2、解决方案设定（Case of Treatment）治疗师签名客人签名Pr actitioner’s Signature Client’s Signature导师签名日期Tutor’s Signature Date精华油配方Essential Oil Blending建议进行治疗时所用的配方精油不多于4种纯精华油；配方内容需包含高、中、低挥发度It is recommended that no more than 4 essential oils be used in a treatment and a full workin knowledge of top notes ,middle notes and base notes is demonstrated in the blend .分别调配适合面部的按摩油并根据客人的肤质使用适当的底油A separate facial oil may required and should include the most suitable carrier oil for the client’s skin type .建议最适合的家居护理的方法：按摩、按压、吸入法、泡浴和香薰等Methods of treatment suitable :Massage /compress /inhalation /baths /burners etc.can be recommended as homecare.。