This online form is for collecting data on the use of essential oils in palliative care and hospice patients. Who *Patient or CaregiverPalliative or Hospice OrganizationPlease choose Patient or Caregiver OR Palliative or Hospice OrganizationOrganization Name *Practitioner Name *FirstLastPatient Initials *Patient Age *Symptom *AnxietyAgitation ConstipationDepressionDyspneaFatigueInfectionInsomniaNausea & VomitingPainOtherOther symptom *Diagnosis *List the diagnosis most associated with the symptom being managed by the essential oil. (Example: Pancreatic Cancer & Nausea)Essential Oil Company *Please enter the name of the supplier Essential oil or blend *ArborvitaeAromaTouchBalanceBasilBergamotBlack PepperBlue TansyBreatheCardamomCassiaCedarwoodCheerCilantroCinnamonCitrus BlissClary SageCloveConsoleCopaibaCorianderCypressDeep BlueDigestZenDouglas FirElevationEucalyptus RadiataFennel (Sweet)ForgiveFrankincenseGeraniumGingerGrapefruitHelichrysumHopeInTuneJasmineJuniper BerryLavenderLemonLemongrassLimeMarjoramMelaleucaMelissaMotivateMyrrhNeroliOnGuardOreganoPassionPastTensePatchouliPeacePeppermintPetitgrainRoman ChamomileRoseRosemarySandalwoodSerenitySiberian FirSpearmintSpikenardTangerineThymeVetiverWild OrangeWintergreenYlang YlangZendocrineSelect all essential oils used in the blenddoTERRA lot numbers *Please indicate all lot numbers used. You can find doTERRA lot numbers on the bottom of each bottle.Other essential oilsEnter names of other essential oils used not listed aboveRoute of administration *AromaticInternalTopicalNumber of drops used (Aromatic) *Indicate the number of drops used aromaticallyNumber of drops used (Internally) *Indicate the number of drops used internallyNumber of drops used (Topically) *Indicate the number of drops used topicallyAromatic route of administration *DiffuserPersonal InhalerCotton Circle/TissuePatchPick the route in which the essential oil was used aromatically. Internal route of administration *Under the TongueCapsuleFood (e.g. honey)Water or Other LiquidPick the route in which the essential oil was given internally. Topical dilution *< 1%1 - 3%4 - 6%7 - 10%> 10%Carrier oil *Aloe VeraArgan Oil Hemp Seed OilCoconut OilJojoba OilTrauma OilOtherOther carrier oil *Were any additional medications used to treat the symptom? *YesNoMedications *Please list any medications that were also used to treat the symptomSide effects *NoneErythema/RednessDizzinessHeadacheNausea PhototoxicityRashOtherAdditional side effects *Please list any additional side effects observedDid the essential oil provide symptom relief? *Strongly AgreeAgreeUndecidedDisagreeStrongly DisagreeWhat percentage did the essential oil reduce pain? *<10%10-25%25-50%50-75%>75%How many hours did the essential oil produce sleep? *<4 hours4-8 hours>8 hoursDid the essential oil treatment reduce or prevent medication use? *Strongly AgreeAgreeUndecided DisagreeStrongly DisagreeWas the patient or caregiver satisfied with the essential oil treatment? *Strongly AgreeAgreeUndecided DisagreeStrongly DisagreeOther CommentsMessageSubmit Consent for Online Research
