Pregnancy Health Questionnaire

Thank you for booking onto our Pregnancy Relaxation Session.

To help us ensure the session is safe, comfortable and tailored to you, we kindly ask you to complete this short questionnaire before attending.

All information will be kept confidential.

About you

First name

Last name

How many weeks pregnant are you?

Is your pregnancy currently classed as low risk?

Yes

No

Unsure

Have you experienced any complications during this pregnancy? (Please tick all that apply)

If you selected 'Other', please provide details

If you ticked any of the above, please provide details

Have you used essential oils or aromatherapy products before?

Yes

No

Do you have any known sensitivities to smells or fragrances?

Yes

No

Is there anything else you would like us to be aware of to help support you during the session?

Please tick to confirm:

I confirm that the information I have provided is accurate to the best of my knowledge.

I understand that aromatherapy products used during the session will be pregnancy-safe and appropriately diluted.

I understand that the session is for relaxation purposes only and does not replace medical care or advice.

I understand that aromatherapy may be adapted or not used if deemed unsuitable.

Signature

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