FIRST & LAST NAME:

EMAIL:

PHONE #:

MAILING ADDRESS: (to get your package to you)

HOW DO YOU PREFER I COMMUNICATE WITH YOU?

Email
Text
Phone Call

MY ESSENTIAL OIL EXPERIENCE:

I have a little experience using essential oils
I have no experience using essential Oils
I have tried some doTERRA Essential Oils before
I use essential oils frequently
I have a diffuser and diffuse oils regularly

1. I HAVE SLEEP CHALLENGES:

I have trouble getting to sleep
I can’t seem to stay asleep
I wake up in the middle of the night and can't get back to sleep
I would like to try essential oils to support a better sleep
Sleep is not an issue

2. I EXPERIENCE STRESS & ANXIETY

Often
Occasionally
Hardly Ever
I would like to try oils to help me feel calmer
I have found ways to manage stress that work for me

3. I STUGGLE WITH HAVING ENOUGH ENERGY TO GET THROUGH THE DAY

Everyday
Occasionally
I would like to try essential oils that support my energy levels
I have all the energy I need

4. I HAVE CHALLENGES WITH AN STOMACH UPSET

Daily
Occasionally
I would like to try essential oil to help calm my belly when needed
This is not an issue for me or my family

5. I STRUGGLE WITH MUSCLE & JOINT PAIN

Daily
Occassionally
I would like to try essential oils that soothe and comfort my muscles and joints
This is not an issue for me

6. I HAVE CHALLENGES WITH ALLERGIES

Daily
Seasonal
Chronic
I would like to try essential oils that help me breathe easier
This is not an issue for me

7. I EXPERIENCE HEADACHES/MIGRAINES

I get headaches with moderate to intense pain
I get tension in my neck & shoulders with moderate to intense pain
I Get Migraines with moderate to intense pain
Migraines with intense pain are a regular part of my life
This is not an issue for me

8. SKIN CARE - doTERRA has 3 Skin Care Lines that support us at different stages of our lives.

I would like to learn about doTERRA’s options for Skincare for myself & my family
I am good with what I am using at the moment

9. TOXIC FREE LIVING - A Variety of Natural Cleaning Options to help us Reduce Our Toxic Load

My families wellbeing is important to me and I would like to learn about my options
I enjoy doing DIY’s and would like to know how to make my own, easy to make cleaning products
I am happy with what I am currently using

In Order of Priority, List Your Top Three Wellness Concerns:
(Add Any Challenges that Are Not Listed Above)

Thank You for Completing this form, I Will Contact You Shortly to Get Your Gift Package to You, to Support Your Wellness Concerns.