Stress Study Intake

Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing? *

Is this address the best for protocol to be mailed if in person drop off is not possible? If NO, please add MAILING address in comments at bottom of form.

Yes- Mail or Drop Off Here

No- See Address In Comments For Mailing

Which Areas of Health and Wellness do you struggle with and could use improvement in your life? *

Help to support:

Stress/Emotion

Pain

Sleep

Digestive

Respiratory

Have you used essential oils before? *

Yes

No

Do you have a wholesale membership account with dōTERRA? *

Yes

No

Not sure

In the past month, how often have you experienced negative issues related to stress or emotions? *

Several times a day

Frequently - daily or almost daily

Sometimes - once a week or so

Rarely - 1-3 times in the past month

How would you rate your stress? *

1 Not stressed at all

2

3

4

5 Overly Stressed

How often do you feel emotionally overwhelmed? *

1 Almost Never

2

3

4

5 Almost Always

How often are you mentally exhausted at the end of the day? *

Rarely

1-2 times per week

3-5 times per week

Daily or almost daily

How often do you feel scatterbrained? *

Rarely

1-2 times per week

3-5 times per week

Daily or almost daily

How often do you feel anxious? *

Rarely

1-2 times per week

3-5 times per week

Daily or almost daily

How often do you have trouble sleeping? *

Rarely

1-2 times per week

3-5 times per week

Daily or almost daily

How often do you feel prolonged sadness or lethargy? *

Rarely

1-2 times per week

3-5 times per week

Daily or almost daily

How often do you take prescription or over-the-counter medication for stress, sleep, or emotional health? *

More than once per day

Once per day

A few times per week

Rarely

Never

After using prescription or over-the-counter medication, how often do you feel common side effects such as stomach pain, loss of appetite, drowsiness, or nausea? *

Always or almost always

Often

Sometimes

Rarely

Never

N/A

Do your emotional health or stress levels prevent you from participating in any normal activities? *

Yes

No

Sometimes

Are you committed to participating in this study for 14 days and sharing your results via a final survey? *

Yes

No