Aromatherapy/EssentialOilQuestionnaire

Aromatherapyisaformofalternativemedicinethatusesessentialoils(EOs),andotheraromaticcompoundsfrom
plantsforthepurposeofaffectingaperson'smoodorhealth.

EmotionalandPsychologicalWellBeing
Rankyourselffrom110(1=donotstrugglewith,10=dailystruggle)
1.Anger(expressed,verbalorphysical) 1 2 3 4 5 6 7 89
2.Anger(unexpressedorinternal) 1 2 3 4 5 6 7 89
3.Anxiety 1 2 3 4 5 6 7 89
4.Apathy 1 2 3 4 5 6 7 89
5.Depression 1 2 3 4 5 6 7 89
6.Suicidalemotionsortendencies 1 2 3 4 5 6 7 89
7.Insomnia 1 2 3 4 5 6 7 89
8.Lethargy(cantgetstarted) 1 2 3 4 5 6 7 89
9.Digestivetrouble 1 2 3 4 5 6 7 89
10.Fear 1 2 3 4 5 6 7 89
11.Grief 1 2 3 4 5 6 7 89
12.LoweredSelfEsteem 1 2 3 4 5 6 7 89
13.Loss/Death 1 2 3 4 5 6 7 89
14.Mentalstress 1 2 3 4 5 6 7 89
15.Calming 1 2 3 4 5 6 7 89
16.Physicalpain 1 2 3 4 5 6 7 89
17.Oversensitivity/Irritability 1 2 3 4 5 6 7 89
18.Spiritualprotection 1 2 3 4 5 6 7 89
19.Stress(overall) 1 2 3 4 5 6 7 89

MajorOrganandMeridianEmotions
Pleaseanswerthefollowingquestionsyesorno.
a. Wouldyousaythatyouhaveahardtimedealingwithsadnessorpossessiveness? Yes No
b. Wouldyousaythatyouhavebeentryingtoohardorperhapspretendingthatyoureok Yes No
whenyourreallynot?
c. Doyoufeelthatyoumaystrugglewithworryingtoomuchorobsessing(aboutanything?) Yes No
d. Doyoustrugglewithanger,resentment,bitternessorfrustrationonaconsistentbasis? Yes No
e. Wouldyouhaveatendencytosaythatyouliveinfear,orstrugglewithfear? Yes No
f. Doyoufeelthatonadaytodaybasisyouhaveatendencytostrugglewithanyorallofthe Yes No
emotionsmentionedabove?

PhysicalSymptomsorAilments
Pleasefillinthecircleifitappliestoyouwithinthelast30days.
Headache Fatigue SorenessinMuscles ChappedSkin
ConstipationorLoose
Tendinitis Nausea ImmunityProblems
Bowels
Stomachupsetsor
Nervousness Faintness/Dizziness Respiratoryproblems
indigestion
Feelingofcoldhands
Painsinchestorheart PoorAppetite Cellulite
andfeet