PRE-STUDY ESSENTIAL OIL USAGE QUESTIONNAIRE - STRESS

Name

First Name

Last Name

Today's Date

YYYY

Phone

(###)

###

####

Age

FOR EACH QUESTION BELOW CHOOSE FROM THE FOLLOWING DROP DOWN MENU

0 – never 1 - almost never 2 – sometimes 3 - fairly often 4 - very often

1. In the last two weeks, how often have you been upset because of something that happened unexpectedly?

2. In the last two weeks, how often have you felt that you were unable to control the important things in your life?

3. In the last two weeks, how often have you felt nervous and stressed?

4. In the last two weeks, how often have you felt confident about your ability to handle your personal problems?

5. In the last two weeks, how often have you felt that things were going your way?

6. In the last two weeks, how often have you found that you could not cope with all the things that you had to do?

7. In the last two weeks, how often have you been able to control irritations in your life?

8. In the last two weeks, how often have you felt that you were on top of things?

9. In the last two weeks, how often have you been angered because of things that happened that were outside of your control?

10. In the last two weeks, how often have you felt difficulties were piling up so high that you could not overcome them?

What were your main sources of stress these last two weeks?

CHECK ALL THAT APPLIES

Health Issues

Relationships

Emotional problems

Life Changes

Money

Social Issues

Other

If you answered OTHER please explain

Pre Study Stress