Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Phone

(###)

###

####

Question 1: Have you ever used essential oils to improve the health concern? *

Choose 1 answer only

YES

NO

Question 2: How often do you feel joint or muscle pain in the last week? *

Choose 1 answer only

Very often

Often

Sometimes Rarely

Never

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: How long have you experienced this pain? *

Choose 1 answer only

Days

Weeks

Months

Years

Question 6: How often do you feel pain from tension or discomfort during the week? *

Choose 1 answer only

Rarely

Once a day

Several times a day

Several times a week

Question 7: After using prescription or over the counter pain medication 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 8: Does your pain stop you from any normal physical activities? *

Choose 1 answer only

Yes

No