This online form is for collecting data on the use of essential oils in palliative care and hospice patients. Please enable JavaScript in your browser to complete this form.Who *Patient or CaregiverPalliative or Hospice OrganizationPlease choose Patient or Caregiver OR Palliative or Hospice OrganizationOrganization Name *Practitioner Name *FirstLastPatient Initials *Patient Age *State *Alabama - ALAlaska - AKAmerican Samoa - ASArizona - AZArkansas - ARCalifornia - CAColorado - COConnecticut - CTDelaware - DEDistrict of Columbia - DCFlorida - FLGeorgia - GAGuam - GUHawaii - HIIdaho - IDIllinois - ILIndiana - INIowa - IAKansas - KSKentucky - KYLouisiana - LAMaine - MEMaryland - MDMassachusetts - MAMichigan - MIMinnesota - MNMississippi - MSMissouri - MOMontana - MTNebraska - NENevada - NVNew Hampshire - NHNew Jersey - NJNew Mexico - NMNew York - NYNorth Carolina - NCNorth Dakota - NDOhio - OHOklahoma - OKOregon - ORPennsylvania - PAPuerto Rico - PRRhode Island - RISouth Carolina - SCSouth Dakota - SDTennessee - TNTexas - TXUtah - UTVermont - VTVirgin Islands - VIVirginia - VAWashington - WAWest Virginia - WVWisconsin - WIWyoming - WYSymptom *AnxietyAgitation ConstipationDepressionDyspnea (Shortness of Breath)FatigueInfectionInsomniaNausea & VomitingPainWoundsOtherLocation of infection *Please indicate what type of infection (e.g. Skin, Sinus etc)Other 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)ForgiveFrankincenseGeraniumGingerGrapefruitGreen MandarinHelichrysumHopeInTuneImmortelleJasmineJuniper BerryLavenderLemonLemongrassLimeMagnoliaMarjoramMelaleucaMelissaMotivateMyrrhNeroliOnGuardOreganoPassionPastTensePatchouliPeacePeppermintPetitgrainPink PepperRoman ChamomileRoseRosemarySandalwoodSerenitySiberian FirSpearmintSpikenardTangerineThymeTurmericVetiverWild OrangeWintergreenYlang YlangZendocrineOtherSelect all essential oils used in the blendEssential oil or blend *ArborvitaeBasilBergamotBlack PepperBlue TansyCardamomCassiaCedarwoodCilantroCinnamonClary SageCloveCopaibaCorianderCypressDouglas FirEucalyptus RadiataFennel (Sweet)FrankincenseGeraniumGingerGrapefruitGreen MandarinHelichrysumJasmineJuniper BerryLavenderLemonLemongrassLimeMagnoliaMarjoramMelaleucaMelissaMyrrhNeroliOreganoPatchouliPeppermintPetitgrainPink PepperRoman ChamomileRoseRosemarySandalwoodSiberian FirSpearmintSpikenardTangerineThymeTurmericVetiverWild OrangeWintergreenYlang YlangOtherSelect all essential oils used in the blendOther essential oilsEnter names of other essential oils used not listed abovedoTERRA lot numbersPlease indicate all lot numbers used. You can find doTERRA lot numbers on the bottom of each bottle.Lot numbersPlease indicate all lot numbers used.Route of administration *AromaticInternalTopicalNumber of drops used (Aromatic) *Indicate the total number of drops used aromaticallyNumber of drops used (Internally) *Indicate the total number of drops used internallyNumber of drops used (Topically) *Indicate the total 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 *Applied neat (undiluted)<5 ml5-15 ml15-30 ml >30 mlCarrier oil *Aloe VeraArgan Oil Coconut OilGrapeseed OilHemp Seed OilJojoba OilLotion Rosehip Seed Oil Tamanu OilTrauma OilMultiple (List Each Carrier Below)OtherOther 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 DisagreeHow long did it take before the essential oil produced a bowel movements? *1 day1-3 days3-5 days>5 daysIf Aquacare was used, did it provide symptom relief? *Strongly AgreeAgreeUndecidedDisagreeStrongly DisagreeN/A- Wasn't usedWhat percentage did the essential oil reduce pain? *<10%10-25%25-50%50-75%>75%What percentage did the essential oil reduce anxiety? *<10%10-25%25-50%50-75%>75%What percentage did the essential oil assist in wound care? *<10%10-25%25-50%50-75%>75%What percentage did the essential oil reduce agitation? *<10%10-25%25-50%50-75%>75%What percentage did the essential oil reduce dyspnea? *<10%10-25%25-50%50-75%>75%What possible symptoms of depression did the essential oil help you with the most?Having little interest or pleasure in thingsFeeling down, depressed, or hopelessFeeling tired or having little energyPoor appetite or overeatingFeeling bad about yourself Trouble concentrating on thingsTrouble falling or staying asleep, or sleeping too muchDifficulty with home or social lifeOtherWhat possible symptoms of the wound did the essential oil help you with the most?HealingOdorInfectionOtherWhat percentage did the essential oil improve fatigue? *<10%10-25%25-50%50-75%>75%What percentage did the essential oil improve your symptom? *<10%10-25%25-50%50-75%>75%What percentage did the essential oil reduce nausea or vomiting? *<10%10-25%25-50%50-75%>75%How many hours did the essential oil produce sleep? *<4 hours4-8 hours>8 hoursHow many days was the essential oil used before the infection was gone? *<3 days3-7 days>7 daysDid 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 DisagreeWere you satisfied with the essential oil treatment? *Strongly AgreeAgreeUndecided DisagreeStrongly DisagreeOther CommentsPhoneSubmit Consent for Online Research
