Online consultation form Please complete the below form if you would like a product range tailored especially for you. All of your answers will be kept totally confidential and we will destroy them if you ask us to. Don’t forget to place an order for the bespoke product that you would like! Please fill this form in with as much detail as possible. We use a totally holistic approach to consider your whole being. The more information that you give us the better products we can make for you.Who is the product being made for? (name) *What is their age? *Has the person got any major illnesses *Town *Postcode *Telephone numberTick the products you want to buy Shampoo / Conditioner Body Wash Hand Wash / Lotion Face Oil / Mask Face Wash / Moisturiser Bath / Massage oilBody Balm Air / Plant sprayAromatherapy Roller Pet productsThe following questions will help us to ensure that the products are suitable for you.Do you or have you ever had an allergic reaction? *YesNoIf so what are you allergic to? *NutsPlants/pollensAnimals/insectsWheat/glutenDairyOtherDetails of allergies *If you have an allergy or sensitivity, how severe is it? *MildSignificantMajorRequiring medical attentionLife threateningAre you receiving medical attention? *YesNoIf so, what for? *Are you taking any medicines? *YesNoIf so, what medicines and for what condition? *Tell us more about you - the more you tell us the better the product will be.Male or female? *MaleFemaleAre you or could you be pregnant? *YesNoMaybeAre you breast feeding? *YesNoHeight in metresWeight in kgDate of birth *Reasons for trying aromatherapyGeneral healthRelaxationUsed it before and liked itUsed it before and want to give it another goAny other reasonOther reasons:Skin The largest organ of the body. This section starts to give us a picture of you and which 100% Organic Essential Oils and Carrier Oils should blended.Skin condition. In general which of the following describes your skin type?DryOilyNormalCombinationSensitiveSun damagedDermatitisEczemaRosaceaDo you suffer from?Spots (white with a head)Spotty (without a white head)Black heads in forehead, nose, mouth, chin areaRosacea on the faceAny other conditionsOther conditions?How are you feeling? Knowing how you feel and how you are is at the heart of providing the best products for youGeneral state of your health at presentFit as a fiddlePretty good all roundSo soNot feeling wellNot well at allOn death's doorPresent weak areas under stressFor example, you may have just lost a loved one, had some bad news, the winter is coming and you feel blue, my arthritis has flared up etc.Recent operations - please give detailsAccidents, injuries or recurring problemsAny weakness? We can help you combat your weaknesses if you tell us what they areMuscular or skeletal problems - neck, back, rheumatism, aches and pains, stiff joints, headachesDigestive problems - constipation, bloating, liver or gall bladder, stomachCirculation problems - heart, blood pressure, fluid retention, tired legs, varicose veins, cellulite, kidney problems, cold hands or feetGynaecological problems - irregular periods, PMT, menopause, HRT, pill - coli, pregnant or trying to conceiveNervous system problems - sensitive, weak, nerve pains, migraine, tension, anxiety, headaches, depressionImmune system problems - prone to infections, sore throats, cold, chest, sinus, regular antibiotics takenAny other problems?Lifestyle True aromatherapy is about helping you as a person with the life you leadStatusMarried/settled downIn a relationshipSingleWidowParentIs your life?Over-busy and stressfulComfortably busyBalanced and happyDull and unstimulatingLonelyProfessional life - happy, long hours, over stretched, ambitious, not appreciated, unhappy in role etcHow often do you exerciseNever - I'd always take the car to the shopsOccasional - I might go for a walk from time to timeRegular - try do get out of breath once a weekFrequent - I enjoy exercise and do it a lotCommitted - waiting to hear about the London MarathonComments on exerciseEnergy levelsVery low - getting out of bed is a challengeLow - can't really be bothered a lot of the timeMedium - generally able to do what I needHigh - always buzzing about doing something or otherManic - so busy I am constantly frazzledSleep patternsInsomniac - Hardly get any decent sleepPoor - typically only around 4 hours uninterruptedAverage - regularly get 8 hours with occasional disruptionGood - sleep like a baby every nightHibernating - 10 hours or more per nightAbility to relaxManic - unable to stop for a momentPoor - very rarely stop to smell the flowersAverage - can usually unwind when I need toGood - able to relax whenever I wantGreat - permanently chilledDo you suffer from?Nervous tensionDepressionAnxietyNone of the aboveHow much natural light do you get each day?None - permanently indoorsSome - only at the weekendFair - get out in the daylight every dayGood - make a real effort to spend plenty of time outdororsGreat - outside all the timeDo you have any time to yourself daily?YesNoSometimesDo you have a creative hobby or interest?YesNoDiet We are what we eat.....Is your diet well balanced?Not at all - white bread and chips all the wayA bit - a piece of fruit from time to timeAverage - I try but often don't succeedPretty good - most of the time I have a balanced dietExcellent - I always make sureDo you try to eat whole foods?You must be jokingOccasionally if there are no chips availableI try to incorporate them into my dietI mainly eat whole foodsSome of my best friends are lentilsDoes your diet regularly contain:Fresh fruitFresh vegetablesRaw foodNuts/seedsProtein (enter source below)Vitamins or supplements (enter details below)Sources of protein (meat, pulses, nuts etc)Vitamins or supplements takenDo you eat regular meals?No - just grab a bite when it suits meMostlyLike clockworkDo you eat in a hurry?I love to take my time over a mealNeither fast nor slowAlways dash through mealsWhat do you drink daily?TeaCoffeeAlcoholFruit juiceHerbal teaFizzy drinksSmoothiesWaterOtherDo you suffer fromFood allergiesBingeingOver eatingUnder eatingWith food in mind are youSweetSavoryBothAromas and senses It is vital that our products are in harmony with you.What smells do you like?Sweet/floralWoodyHerbs like rosemary, sage, thymeFruityCitrusFirey - ginger, black pepper, peppermintVanillaOther (please specify)Other smells I like:Would you describe yourself as:DryMoistHotColdYinYangProduct specifics Our different products need different information from you. Choose which products you fancy and help us tailor them to you.I am interested in these bespoke products:Massage oils and lotionsBathing productsShampooHair conditionerHand washAir spraysMassage oils and lotions We want to keep your skin in top shape, encouraging equilibrium between mind and body, ensuring that the balance is finely tuned. To do this we need to nourish the skin (the largest organ of the body) with either 100% pure natural organic plant based carrier oils (the thick lustrous nourishing oils like Sunflower, Argan etc) or a wonderful natural body lotion. To these carriers/lubricants, we will blend some of the finest organic essential oils, with properties including pain relief, anti inflammatory, warming, cooling, uplifting, relaxing, balancing, anti-septic, etc .First decide the type of carrier (lubricant) and where you'd like to massage itPlant based carrier oilWhole bodyFace and lipsHands, feet and nailsBody lotionWhole bodyFace and lipsHands, feet and nailsWhat properties would you like your massage product to have?Anti-ageingRelaxingStimulatingWarmingNourishingFor your ailmentsWhich ailments would you like it blended for?What properties would you like your product to have?Bespoke bathing products We have body wash or bath oil that soaks into your skin leaving it feeling soft and silky. Please answer the questions below so that bespoke products can be designed especially for you. Bathing products I am interested in:Body washBath oilBody wash properties I am looking for:Fresh and zesty, get me up in the morningRelaxing to help me sleep at nightSpecially for my ailmentsOther properties (please) specifyHow would you describe the best shower gel you could possibly have?Bath oil properties I am looking for:Fresh and zesty, get me up in the morningRelaxing to help me sleep at nightSpecially for my ailmentsOther properties (please) specifyAilments I would like my bath oil to relieveOther properties I am looking for from my bath oilIf you are looking for a 6 week intensive course, how often do you bathe per week?1 or less234567 or moreHow would you describe the best bath oil you could possibly have?Bespoke shampoo and conditioner We all like our hair to look its best. Hand made, natural products prepared specially for you give the very best results How long is your hair?Bald as a cootShaved and shortMedium and magnificentLong and luxuriousRapunzel would be jealousWhat colour is your hair?WhiteGreyBlondeBrownAuburnRedBlackHighlightedColouredDo you have extensions in your hair today?YesNoDo you have chemical treatments in your hair today?YesNoWhat treatments do you have?Would you describe your hair as:DryGreasyNormalFine/fly awayThinningItchy & flakyOther (please specify)Other hair conditionHow often do you wash your hair?1 or less234567 or moreDescribe the qualities that you would like from your shampooHow often do you condition your hair?1 or less234567 or moreDescribe the qualities that you would like from your conditionerBespoke hand wash Our hands are always in use and often in tough conditions. Our hand made products help them to stay soft and lovely.How would you like your handwash to be?AntisepticFloweryFruityFresh and mintyNourishingOther (please specify)Other handwash propertiesDescribe the best handwash you could possibly haveAir sprays There is nothing better than walking into a room that has a lovely smell. Even better if you have chosen the smells yourself!.Choose an Air Spray Fresh and zesty to wake you up in the morningFlowery and relaxing Woodland scented Insects Blended especially for your ailments (please specify)Perfect for aiding growth for indoor plantsNameSubmit your online aromatherapy consultation
