Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone

(###)

###

####

Question 1: How often did you feel indigestion in the last two weeks? *

Choose 1 answer only

Very often

Often

Sometimes

Rarely

Never

Question 2: Are you often experiencing any of the following symptoms in the last 2 week? *

Click all that applies to you

gas & bloating

constipation

diarrhea

pain

Question 4: How often did you take prescription or over the counter medicines for your issues over the last two weeks? *

Choose 1 answer only

Rarely

Once a day

Several times a day

Several times a week

Question 5: Did you experienced relief with these digestive issues? *

Choose 1 answer only

Yes

No

Question 6: After using the Essential Oils how often did you feel common side effects (eg. Stomach pain, loss of appetite, drowsiness, nausea)? *

Choose 1 answer only

Very often

Often

Sometimes

Rarely

Never

Question 7: Did your digestive issues stop you from any normal physical activities over the last two weeks? *

Choose 1 answer only

Yes

No