Aromatherapy Intake & Safety Assessment

Date and time of encounter: [Date and time]

Setting: [clinic / home / other]

Patient name and identifiers: [Patient full name and identifiers per local policy]

Preferred name and pronouns: [Preferred name and pronouns, or "not provided" / "patient declined"]

Practitioner name and credentials: [Practitioner name, degree(s), credentials]

Source of history: [patient / caregiver / chart review] (If interpreter present, note language.)

Data sources reviewed: [List of data sources reviewed, e.g., patient report, medication list, outside records] (Note any limitations.)

Reason for Visit and Goals

[Patient-stated reason for seeking aromatherapy and primary goals] (1–3 sentences. Include chief concern, explicit goals such as relaxation, sleep support, nausea management, stress reduction, or room scenting; what success would look like; referral source; prior approaches that have not worked. Use a brief patient quote only if it adds meaningful clarity. Do not infer an indication from scent preference alone.)

Scope and Consent

[Attestation of scope explanation, patient understanding, and consent status] (Document that aromatherapy was explained as complementary/supportive care and that patient understands essential oils can cause irritation, sensitization, or adverse effects. Note consent to proceed with intake and any in-visit exposure such as smell testing or patch testing. For minors, document guardian consent and patient assent.)

Prior Aromatherapy and Fragrance Exposure

Experience with essential oils/fragrances: [Summary of prior use, or "no prior aromatherapy experience reported"] (Include routes used: inhalation via diffuser/steam, topical diluted or undiluted, bath, ingestion; products and specific oils with brand/source if known; typical frequency and duration; setting of use including ventilation.)

Prior adverse reactions: [Description of any prior reactions, or "no prior adverse reactions reported"] (For each reaction, document: suspected agent and route, time to onset, symptoms, severity, treatment required, outcome, tolerance of related products since, and causality certainty. Do not label as "true allergy" unless explicitly supported; use "reaction" or "sensitivity" and describe phenotype.)

Safety and Contraindication Screening

(For each area, document status as: Yes / No / Unknown / Not Assessed. Use "No" only when explicitly asked and answered negatively. Include relevant details when positive.)

Respiratory

Status: [Yes / No / Unknown / Not Assessed]

[Details if positive] (Include asthma, COPD, chronic cough, vocal cord dysfunction, fragrance-triggered symptoms; typical triggers; baseline control; rescue inhaler use; recent exacerbations; whether scents have caused wheeze or bronchospasm.)

Migraine and Odor Sensitivity

Status: [Yes / No / Unknown / Not Assessed]

[Details if positive] (Include migraine diagnosis; whether odors trigger or worsen headaches; osmophobia; nausea or photophobia with scent exposure; syncope or panic with strong odors. Document odor sensitivity even without formal migraine diagnosis.)

Seizure History

Status: [Yes / No / Unknown / Not Assessed]

[Details if positive] (Include epilepsy, febrile or unexplained seizures; date of last seizure; current control; antiseizure medications.)

Skin and Photosensitivity

Status: [Yes / No / Unknown / Not Assessed]

[Details if positive] (Include contact dermatitis, eczema, atopic dermatitis, photosensitivity disorders, severe sun reactions, past reactions to citrus topicals or perfumes on sun-exposed skin; current sun exposure patterns if topical citrus oils may be considered.)

Pregnancy and Lactation

Status: [Yes / No / Unknown / Not Assessed]

[Details if applicable] (Include current pregnancy status and gestational age; breastfeeding status; trying to conceive; whether OB/midwife has been consulted. Document explicitly if patient has childbearing potential.)

Special Populations and Environment

Status: [Yes / No / Unknown / Not Assessed]

[Details if positive] (Include pediatric or geriatric considerations; cognitive impairment affecting safe use; household risks such as small children, pets, shared living spaces; workplace scent restrictions; ability to follow dilution and ventilation instructions.)

Medications, Supplements, and Allergies

Current medications and products: [List of current prescription medications, OTC products especially topicals/menthol rubs/inhalants, herbals and supplements, and relevant PRN meds] (Note source: patient recall vs verified list; document any gaps or uncertainties.)

Allergies and sensitivities: [Drug allergies with reaction phenotype; topical/cosmetic/fragrance reactions with agent and reaction type; environmental sensitivities relevant to aromatherapy; food allergies relevant to carrier oils] (If patient is uncertain about allergy history, document this explicitly.)

Relevant History

[Targeted past medical and social history relevant to scent and skin exposure risks] (Include pertinent respiratory, neurologic, dermatologic conditions not already captured; occupation; fragrance-free workplace requirements; household constraints affecting implementation. Keep brief.)

Examination

(Include only if exam was performed; otherwise omit section or state "examination not performed.")

Vital signs: [Vital signs if obtained]

Focused respiratory exam: [Findings if indicated]

Skin inspection: [Findings if topical use planned or prior dermatitis reported]

In-visit exposure response: [Any smell testing or patch testing with start/stop times, observed symptoms, patient-reported tolerance]

Assessment

(Problem-oriented synthesis. For each problem, provide 1–3 line summary and overall risk level.)

[Problem 1: Presenting goal or symptom]

[Synthesis of clinical context, identified safety constraints, and implementation constraints]

Overall risk level for aromatherapy exposure: [low / moderate / high] — [Brief justification]

[Problem 2: Additional issue if applicable]

(Add additional problems as needed following same structure.)

Plan

Recommended approach: [Planned routes: inhalation vs topical; routes to avoid; setting and ventilation assumptions; duration limits for exposure]

Topical application details: [Carrier type, target dilution %, application sites, sites to avoid, phototoxic oil precautions] (If applicable.)

Patient preferences integrated: [Preferred scent profiles, aversions, known triggers to avoid]

Safety counseling provided: [Topics covered, including: skin irritation/sensitization precautions, avoiding eye/mucous membrane exposure, avoiding ingestion, phototoxicity precautions for topical citrus oils, respiratory warning signs requiring discontinuation]

Follow-up: [Interval and mode] (Specify what will be assessed: tolerance, symptom response, adverse events.)

Urgent symptoms and instructions: [What to do, when to seek urgent care, whom to contact]

Care coordination: [Plan to coordinate with other clinicians if applicable]

Practitioner signature: [Name, credentials] Date: [Date]