Smell Recovery and Revitalization

Please complete our intake form

Phone

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Name(Required)

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Email(Required)

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Date of Birth(Required)

Gender

Female

Male

Other

Age(Required)

Occupation(Required)

How would you describe your current ability to smell?(Required)

I have no sense of smell

I have a diminished sense of smell

I have become extremely sensitive to odors

I smell things that aren’t there

When I smell something, it smells different than expected

Is there anything else about your current sense of smell that I should know?(Required)

How long have you noticed this change in olfaction?(Required)

Do you know the root cause of this change?(Required)

Have you tried any kind of Smell Training in the past to help with this issue? If so, please explain.(Required)

How has this change in olfaction affected your daily life?(Required)

Is there anything that you do that improves your sense of smell?(Required)

Is there anything that makes it worse?(Required)

Has this change in olfaction also affected your sense of taste?(Required)

Do you have any of the following health conditions? Choose all that apply:

Do you have any allergies? Please list:(Required)

Is there another health issue that that would be important for me to know about?(Required)

Are you under the care of a physician or therapist? If so, please list any diagnosis or conditions that you are being treated for.(Required)

Are you currently experiencing any skin conditions?(Required)

Yes

Please list any prescribed medications, over the counter drugs and/or supplements that you are currently taking:(Required)

Are you extra sensitive to any kind of essential oil or fragrance (Hyperosmic)? Please explain.(Required)

Are you currently undergoing treatment for cancer?(Required)

Yes

Are you breastfeeding?(Required)

Yes

Do you have multiple chemical sensitivity?(Required)

Yes

Are you pregnant or trying to become pregnant?(Required)

Yes

How many hours of sleep do you get each night?(Required)

Do you consume caffeine?(Required)

Yes

If so, how many cups per day?

Do you have pets in the house?(Required)

Yes

Do you use tobacco?(Required)

Yes

Is there a pregnant person in the house?(Required)

Yes

Are there small children in your house?(Required)

Yes

Are there elderly people in your house?(Required)

Yes

Do you own an essential oil diffuser?(Required)

Yes

What are your favorite foods?(Required)

What are your favorite aromas or essential oils? List as many as you like. These can be things like coffee, baked bread or lavender essential oil.(Required)

Please rank these scent profiles in order of preference (#1 being the profile you like the most). 

Fruity (ex. Lemon, Bergamot, Orange…)(Required)

Please enter a number from 1 to 4.

Flowery (ex. Lavender, Ylang Ylang, Rose…)(Required)

Please enter a number from 1 to 4.

Spicy (Cloves, Tea Tree, Cinnamon etc.)(Required)

Please enter a number from 1 to 4.

Resinous (Eucalyptus, Cedarwood, Fir…)(Required)

Please enter a number from 1 to 4.

Are there any aromas that you absolutely do not like or that might provoke a trauma response?(Required)

Have you ever worked with aromatics or essential oils in a therapeutic way before? If yes, please explain.(Required)

Terms

I have stated all my known conditions and have answered all questions honestly. I take it upon myself to keep the practitioner updated on my health.

I understand that the consultant does not diagnose, prevent or treat illness, disease, or any other physical or mental conditions. I understand that this treatment is not a substitute for medical treatments and/or diagnosis, and it is recommended that I see a qualified professional for any physical or mental condition that I may have. I understand this treatment is not a substitute for medical care.

I understand the following:

I am not being advised to take any essential oil products internally.
I must keep all essential oil products out of the reach of children.
Essential oils could be poisonous if swallowed.
Essential oils must be stored in a cool, dark place.
Essential oils may irritate the skin if not stored or used properly.
Essential oils must not be used with animals.
Essential oils must not be used on the skin of babies or children under 1 year old.
Essential oils must be used with extreme caution for children under 5 years old.

I hold my Aromatics Therapist consultant, Maureen Serrao Cole, harmless for any injuries or negative effects I may experience as a result of using the products I receive from this consultation.

I hold Lift Aromatics harmless for any injuries or negative effects I may experience as a result of using the products I receive from this consultation.

Click box to agree to above terms:(Required)

Yes, I agree to the terms.

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