Flower Essence Questionnaire

Flower Essence Questionnaire

Complete this questionnaire to begin your journey of holistic, medicinal energetic properties of plants that stimulate the body's ability to regain and maintain healthy function and balance. Click the box next to each question to which you give a definite YES answer. If your answer is NO, or Sometimes, to any question below, leave the box unchecked.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
I hide my feelings behind a facade of cheerfulnessI dislike arguments and often give in to conflictI turn to food, work, alcohol, drugs, etc. when down
I have trouble letting go of old habbitsI need a new start in lifeIve experienced trauma or abuse
I feel anxious without knowing whyI have a secret fear that something bad will happenI wake up feeling anxious
I've experienced pain, inappropriate power or abuse from a father figure or men in childhoodI feel tender and sensitiveI feel insecure with intimacy
I get annoyed by the habits of othersI focus on others' mistakesI am critical and intolerant
I feel extreme Co-dependanceI feel broken heartedI am over come by grief
I often neglect my own needs to please othersI find it difficult to say "no"I tend to be easily influenced
I constantly second-guess myselfI seek advice, mistrusting my own intuitionI often change my mind out of confusion
I'm afraid I might lose control of myselfI have sudden fits of rageI feel like I"m going crazy
I make the same mistakes over and overI don't learn from my experienceI keep repeating the same patterns
I need to be needed and want my loved ones closeI feel unloved and unappreciated by my familyI easily feel slighted and hurt
I often feel spacey and absent-mindedI find myself unable to concentrate for longI get drowsy and sleep more than necessary
I am overly concerned with cleanlinessI feel unclean or physically unatractiveI tend to obsess over little things
I have little zest for lifeI keep busy to avoid feeling emotional painI put undue pressure on myself
I feel overwhelmed by my responsibilitiesI don't cope well under pressureI have temporarily lost my self-confidence
I become discouraged with small setbacksI am easily disheartened when faced with difficultiesI am often skeptical and pessimistic
I feel hopeless, and can't see a way outI lack faith that things could get better in my lifeI feel sullen and depressed
I have trouble speaking upI get anxious about having to speak in publicI feel disconnected from my body and mind
I am obsessed with my own troublesI dislike being alone and I like to talkI usually bring conversations back to myself
I have a crippling fear of confrontationI cannot stop negative thoughts and feelingsI feel like a victim
I am suspicious of othersI feel discontented and unhappyI am full of jealousy, mistrust, or hate
I'm often homesick for the "way it was"I think more about the past than the presentI often think about what might have been
I often feel too tired to face the day aheadI feel mentally exhaustedI tend to put things off
I find it hard to wait for thingsI am impatient and irritableI prefer to work alone
I lack self-confidenceI feel inferior and often become discouragedI never expect anything but failure
I am afraid of things such as spiders, illness, ec.I am shy, overly sensitive, and modestI get nervous and embarrassed
I feel nervous and emotionalI am tenderheartedI have had past conflicts with a mother or mother figureType option 4
I get depressed without any reasonI feel my moods swinging back and forthI get gloomy feelings that come and go
I tend to overwork and keep on in spite of exhaustionI have a strong sense of duty and never give upI neglect my own needs in order to complete a task
I feel completely exhausted, physically and/or mentallyI am totally drained of all energy with no reserves leftI have just been through a long period of illness or stress
I feel unworthy and inferiorI often feel guiltyI blame myself for everything that goes wrong
I am overly concerned and worried about my loved onesI am distressed and disturbed by other people's problemsI worry that harm may come to those I love
I feel like the odd one out or outcastI have experienced social isolationI don't feel like I belong and lonesome
I sometimes feel terror and panicI become helpless and frozen when afraidI suffer from nightmares
I set high standards for myselfI am strict with my health, work and/or spirtual disciplineI am very self-disciplined, always striving for perfection
I find it difficult to make decisionsI often change my opinionsI have intense mood swings
I feel devastated due to a recent shockI am withdrawn due to traumatic events in my lifeI have never recovered from loss or fright
I feel extreme mental or emotional heartacheI have reached the limits of my enduranceI am in complete despair, all hope is gone
I have an addiction (any kind)I feel like I have hit rock bottomI have been exposed to deep hurt, trauma and pain sexually
I get high-strung and very intenseI try to convince others of my way of thinkingI am sensitive to injustice, almost fanatical
I tend to take charge of projects, situations, etc.I consider myself a natural leaderI am strong-willed, ambitious, and often bossy
I am experiencing change in my life: a move, new job etc.I get drained by people or situationsI want to be free to follow my own ambitions
I give the impression that I'm aloofI prefer to be alone when overwhelmedI often don't connect with people.
I am constantly thinking unwanted thoughtsI relive unhappy events or arguments over and over againI am unable to sleep at times because I can't stop thinking
I can't find my path in lifeI am drifting in life and lack directionI am ambitious but don't know what to do
I have been hurt deeply or experience grief and sadness oftenMy heart feels brokenI feel no joy in life
I feel resentful and bitterI have difficulty forgiving and forgettingI think life is unfair and have a "Poor me attitude"
alcohol (brandy)apple cider vinegar
Telephone, using the phone number I've listed aboveVideo, Tara will share connection details before the appointment
Please verify that you are human*
Spa Schwa values your privacy. We do not rent, sell, or share personal information about you with other people or non-affiliated companies. Please visit our website for more information on our privacy policy.
Should be Empty: