Step 1 of 5 20% Patient InformationFirst Name:*Last Name:*Sex*Birth Date* Date Format: MM slash DD slash YYYY Age*Occupation:*City*ProvinceEmail* PhoneMobileParent/Guardian:* Patient InformationChronic Conditions: (please check)High Blood PressureYesNoDiabeticYesNoCancerYesNoLiver DiseaseYesNoKidney DiseaseYesNoDepressionYesNoEpilepsyYesNoOtherYesNoAllergiesMedication:Surgeries:Are you currently under the care of Physician? If so, please list the conditions (s) you are being treated for.Are you pregnant?Are you breastfeeding? Social HistoryHow many hours of sleep do you usually get per night during the week?*How much per day do you use of the following?A) Coffee, tea, soft drinks, energy drinksB) Alcohol:C) Cigarettes, cigars, vapor: Enter #D) Other drugs:Please describe your exercise regimen. Hours per week.Limited exercise Reason For Your VisitWhat is your primary concern?Day/Month/Year of onset of concern: Date Format: MM slash DD slash YYYY Your idea of the cause:What have you tried that makes it feel better:What makes it feel worse? Aroma QuestionAre there any scents or aromas that disturb you?Do you have allergic reactions to scents? If so, which ones.Are there any scents or aroma that you especially enjoy?Other Concerns:Do you have any other concerns?
