Health History Form with Your Aromatherapy Blends


Please fill out this form which will help me understand your health issues and assist in selecting essential oils appropriate for your situation. Your submission of this form indicates you have read and understood:

Our LEGAL DISCLAIMER: The educational information, traditional folk remedies, current health discoveries & uses described on this site & blog about therapeutic essential oils & hydrosols do not replace standard medical practices of any country.

Under the scope of my CCA clinical training & ethical professional practices, I am not permitted to diagnose, prescribe, or make medical claims. For medical issues, always obtain an accurate diagnosis from your licensed medical practitioner before working with a certified essential oils consultant educator.

Contact Us


  • Aromatherapy Consultation

  • Your Contact Information

  • When did you first use essential oils? Occasionally? Regularly?
  • Health History

  • If EPILEPSY is a problem, suffer with DIZZINESS or MENTAL ILLNESS, let us know.
  • If you have allergies, please give us details on what you are allergic to, how long the allergies have been bothersome, triggers for allergic responses, etc.
  • Please give us details on the severity of your asthma, how long you've had asthma, triggers for an asthmatic response, etc.
  • Any major illnesses or hospitalizations due to sickness.
  • Broken bones, auto accidents, falls, etc.
  • Please list medications you may be taking for health issues / illnesses, dosages, and how long you've been taking the prescription, etc.
  • Please note any Vitamins, Pro-Biotics, Super Foods, etc. you use on a daily or regular basis.
  • Please rank YOUR preferences: Most Liked to Least Preferred for each fragrance category. If you REALLY DISLIKE any aromas, let us know that, too.
  • How did you learn about & our Essential Oils Blog
  • This field is for validation purposes and should be left unchanged.

Cynthe Brush

Certified Clinical (Medical) Aromatherapist
Creating Custom Blends Since 1999

Therapeutic Essential Oils Practitioner & Self-Care Health Educator has used essential oils for personal, family, & client health issues since 1999.

Personal Consultations:
Pre-paid on an hourly basis

Gaia’s Pharmacopeia Buy Healing Essential Oils Blends / 100% Natural Botanical Perfumes:
Effective essential oil blends for Athletic Injuries; Sprains – Broken Bones; Wounds & Surgeries; Backaches; Headaches; Dizziness; Herpes Simplex; Stress and more.