姓名 Name
*
First Name
Last Name
電郵 Email
*
年齡 Age
性別 Gender
*
職業 Profession
婚姻狀況 Marital Status
未婚 Not Married
已婚 Married
分居 Separated
離婚 Divorced
喪偶 Widowed
子女數目 No. of children (if applicable)
對上一次月經日期（來潮首天） Date of last period (First Day)
MM
DD
YYYY
您是否懷孕或正在哺乳？Are you pregnant or breastfeeding?
您曾否經歷任何手術？如有，請列出手術原因、日期及後續問題。Have you ever undergone any surgeries? If yes, please list the reason for the surgery, the date, and any subsequent issues.
您有否任何慢性或嚴重疾病？如有，請列出疾病及病發日期。Do you have any chronic or serious illnesses? If yes, please list the illness and the date of onset.
您兩年內有否經歷任何意外事故或受傷？如有，稱列出事故及發生日期。Have you experienced any accidents or injuries within the past two years? If yes, please list the incidents and the dates they occurred.
您目前是否在服用任何藥物？如有，請列出。Are you currently taking any medications? If yes, please state.
您是否有任何已知的過敏或敏感性？如有，請列出。Do you have any known allergies or sensitivities? If yes, please state.
您是否曾對精油或其他芳療產品有過不良反應？如有，請列出。Have you ever had any adverse reactions to essential oils or other aromatherapy products? If yes, please describe.
您這次香薰治療諮詢的主要目標是什麼？What are your primary goals for this aromatherapy session?
您有否任何特定的不適或關切的地方？如有，請描述。Do you have any specific areas of discomfort or concern? If yes, please describe.
同意及承認 Consent and Acknowledgment
提交此表格，即表示您確認：
By submitting this form, you acknowledge that:
1. 您提供的信息是準確和完整的，並且您已經盡力而為。You have provided accurate and complete information to the best of your knowledge.
2. 您理解芳療不能取代專業醫療護理。You understand that aromatherapy is not a substitute for professional medical care.
