Couture Fragrance Evaluation

Evening Phone:

Part 1

Date:*

Name:*

Address:*

City:*

State:*

Zip:*

Marital Status:

Name of Spouse/Signigicant other:

Children's Names and Ages:

Occupation:

Date of Birth:

Gender:

Hair Color:

Skin Type:

Skin Tone:

Birth Control or Hormone Medication:

Do you engage in strenuous activity every day?

Do you eat fruit every day?

Do you eat spicy foods?

What is your type of diet?

What is your personality type?

Do you perspire often?

Do you feel yourself to be in generally good physical health?

Do you feel yourself to be in generally good mental health?

Select one answer from the choices below.

Which activities appeal to you most:

Which Music appeals to you most:

Which Aromas appeal to you most:

Which Entertainment appeals to you most:

Which Color Groups appeal to you most:

Favorite Color:

Least Favorite Color:

Favorite Season:

Least Favorite Season:

How much time, on average, do you spend outside?

Do you like animals?

Favorite Animal:

Least Favorite Animal

Do you like the water?

Which is your favorite?

How often do you listen to Music?

Favorite Food:

Least Favorite Food:

How often do you eat raw fruits and/or vegetables?

How many hours of sleep do you average per night?

Do you remember dreams?

What makes you the happiest?

What scares you the most?

Are you happy?

Part II

List all known allergies:

Height:

Weight:

Has your height or weight changed in recent months/years?

Do you have any special needs to be considered?

Overall physical condition:

Major life changes in the past year (new job, baby, death in family, divorce, child leaving home, retirement, etc:

Health Habits

Exercise beyond normal daily activities and chores?

Describe the exercise (including how often, and how long)

Smoker?

List Current Medications:

Medical History: Check all that apply to you now or in the past:

Allergies/Asthma

Emphysema/C.O.P.D.

Other Lung Problems

Heart Problems

High Blood Pressure

Circulation Disorders

Stroke/TIA

Diabetes

Cancer - Type:

Seizures/Epilepsy

Neurological Problems

Depression

Anxiety

Digestive Disorders

Infectious Diseases

Hepatitis

HIV/AIDS

Other

Thyroid Problems

Skin Problems

Arthritis

Back Problems

List and give approximate year of any other major illnesses, conditions, surgeries or accidents you have experienced:

Is there any health-related reason why you should not participate in an excercise program?

What is your objective and what do you hope to achieve by working with an Aromatherapist?

Email Address:*

Client Questionnaire

Daytime Phone:*

*Required Field

You must understand that Aromatherapeutics engages the use of highly concentrated whole botanical oils and therefore should always be used with caution and under the supervision of a certified Aromatherapist. Essential oils should always be kept out of the reach of children and a skin patch test is recommended before use to determine sensitivity and or allergic reaction.

Single Married Male Female Brown Blonde Red Oily Normal Dry Dark Medium Fair Yes No Yes No Yes No Yes No High Fat Low Fat Extrovert Introvert Yes No Yes No Yes No A. Outdoor and water sports, hiking, horseback riding B. Gardening, making gifts for loved ones, writing C. Scuba diving, chess D. Working out at the gym, parties, competitive sports E. Victorian tea parties, rose gardens, collecting beauty F. Shopping, decorating, gourmet dining G. Art galleries, seminars, French foods H. Entertaining, potluck suppers I. Museums, old houses, concerts, travel abroad A. Mood Music B. Vivaldi, songs with a message C. Rock & Roll D. Jazz E. Love Songs, Show Tunes F. Classical G. Opera H. Top 40 I. Concertos A. Fresh air, seaspray, citrus B. English roses, flower shops, scented candles C. Cinnamon, ginger, nutmeg, moss D. Walking in the woods, linens dried in the breeze E. Apple pie, birthday cake, fresh peaches F. Incense, gardenias, night jasmine G. Blackberries, fragrant wood, lilies H. Freshly mown grass, oranges, ocean air I. Old books, leather, raspberries A. Meadow picnics, zoos, canoe rides B. Art and craft shows, reading in a hammock C. Coffee Houses, playhouses D. Dancing the night away, good conversation, midnight swim E. Candlelit dinners, bubble baths F. Relaxing massage, traveling, dining nude G. Theater & ballet, vintage wine H. Making new friends & cherishing old ones, ice cream socials, circuses I. Flower shows and garden tours, designer houses A. Nature Colors B. Pastels C. Natural & Deep Tones D. Southwest colors E. Colors of sunsets & moonlight F. Rich Tones, creams & ivory G. Black, White & Red H. Rainbow hues I. Jewel tones Yes No Yes No Ocean Lake River Pond Stream Every Day Every Meal Weekly Yes No Poor Fair Good Excellent Yes No Yes No

After you click Submit, you will be directed to the Color Wheel Evaluation