Bach Flower Essence Questionnaire

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Today's Date

Date

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Name

First Name

Last Name

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Preferred Method of Contact

Text

Phone Call

Email

Doesn't matter

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To be filled out by Bach Flower Consultant. Bach Flower Personal Blend is:

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Email

example@example.com

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Phone Number

Area Code

Phone Number

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Mailing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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How did you hear about SimlyWellness?

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What areas in your life do you want to work on and why? What do you think is triggering your stress?

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Do you experience Panic Attacks? If yes, please explain how often and the severity.

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Do you have a pre existing medical condition? If yes, please list and explain. (Cancer, Auto Immune Disease, etc.)

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How would you describe your understanding of these beautiful Flower Essences? Enter 0-5; 0 - Don't know what they are, 5 - I've used or used them and understand how they work?

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AgrimonyBalanced Outcome: Cheerfulness stems from a real sense of self-acceptance and inner joy.

I hide my feelings behind a façade of cheerfulness

I dislike arguments and often give in to avoid conflict

I turn to food, work, alcohol, drugs, etc. when down

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AspenBalanced Outcome: A state of inner peace, security and fearlessness.

I feel anxious without knowing why

I have a secret fear that something bad will happen

I wake up feeling anxious

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BeechBalanced Outcome: Tolerance and a sense of compassion for and unity of others.

I get annoyed by the habits of others

I focus on others' mistakes

I am critical and intolerant

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CentauryBalanced Outcome: Become in touch with what you want and follow your own path.

I often neglect my own needs to please

I find it difficult to say "no"

I tend to be easily influenced

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CeratoBalanced Outcome: Trust your own inner wisdom and follow it. Self-assured and decisive.

I constantly second-guess myself

I seek advice, mistrusting my own intuition

I often change my mind out of confusion

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Cherry PlumBalanced Outcome: A calm mind and are able to think and act rationally.

I'm afraid I might lose control of myself

I have sudden fits of rage

I feel like I'm going crazy

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Chestnut BudBalanced Outcome: Observe your own mistakes with objectivity, and learn from it.

I make the same mistakes over and over

I don't learn from my experience

I keep repeating the same patterns

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ChicoryBalanced Outcome: Able to care for others unselfishly, offering genuine maternal love.

I need to be needed and want my loved ones close

I feel unloved and unappreciated by my family

I easily feel slighted and hurt

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ClematisBalanced Outcome: Interest in the world around, and enjoyment of life.

I often feel spacey and absent minded

I find myself unable to concentrate for long

I get drowsy and sleep more than necessary

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Crab AppleBalanced Outcome: Acceptance of oneself and one's imperfections.

I am overly concerned with cleanliness

I feel unclean or physically unattractive

I tend to obsess over little things

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ElmBalanced Outcome: Restoration of one's normal capable personality and self-assurance.

I feel overwhelmed by my responsibilities

I don't cope well under pressure

I have temporarily lost my self-confidence

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GentianBalanced Outcome:Realization that there is no such thing as failure when doing your best.

I become discouraged with small setbacks

I am easily disheartened when faced withdifficulties

I am often skeptical and pessimistic

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GorseBalanced Outcome: Sense of faith and hope, despite current physical or mental problems.

I feel hopeless, and can't see a way out

I lack faith that things could get better in my life

I feel sullen and depressed

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HeatherBalanced Outcome: Good listener who is generous in helping others. Selfless

I am obsessed with my own troubles

I dislike being alone and I like to talk

I usually bring conversations back to myself

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HollyBalanced Outcome: Generous-hearted person able to give without making demands.

I am suspicious of other

I feel discontented and unhappy

I am full of jealousy, mistrust, or hate

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HoneysuckleBalanced Outcome: Ability to live in the present, able to move forward in life without regret.

I'm often homesick for the "way it was"

I think more about the past than the present

I often think about what might have been

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HornbeamBalanced Outcome: Certainty of one's strength and ability to face the day's work.

I often feel too tired to face the day ahead

I feel mentally exhausted

I tend to put things off

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ImpatiensBalanced Outcome: Someone who is decisive and spontaneous, less hasty in action.

I find it hard to wait for things

I am impatient and irritable

I prefer to work alone

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LarchBalanced Outcome: Determined, capable, with a realistic sense of self-esteem.

I lack self-confidence

I feel inferior and often become discouraged

I never expect anything but failure

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MimulusBalanced Outcome: Quiet courage to face trials and difficulties with humor and confidence.

I am afraid of things such as spiders, illness, etc.1

I am shy, overly sensitive, and modest

I get nervous and embarrassed

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MustardBalanced Outcome: Return of joy, supported by an inner stability and peace.

I get depressed without any reason

I feel my moods swinging back and forth

I get gloomy feelings that come and go

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OakBalanced Outcome: Restores their energy and helps them recognize the need to take time off.

I tend to overwork and keep on in spite of exhaustion

I have a strong sense of duty and never give u

I neglect my own needs in order to complete a task

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OliveBalanced Outcome: Restoration of strength, vitality and interest in life. Peace of mind.

I feel completely exhausted, physically and/ or mentally

I am totally drained of all energy with no reserves left

I have just been through a long period of illness or stress

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PineBalanced Outcome: Accept responsibility realistically and have sound judgement.

I feel unworthy and inferior

I often feel guilty

I blame myself for everything that goes wrong

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Red ChestnutBalanced Outcome: Ability to care for others with compassion but without anxiety.

I am overly concerned and worried about my loved ones

I am distressed and disturbed by other people's problems

I worry that harm may come to those I love

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Rock RoseBalanced Outcome: Courage and presence of mind. The person is calm and self-forgetful.

I sometimes feel terror and panic

I become helpless and frozen when afraid

I suffer from nightmares

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Rock WaterBalanced Outcome: Ability to hold high ideals with flexible mind. Willing to change minds.

I set high standards for myself

I am strict with my health, work &/or spiritual discipline

I am very self-disciplined, always striving for perfection

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ScleranthusBalanced Outcome: Certainty and decisiveness with poise and balance in all circumstances.

I find it difficult to make decisions

I often change my opinions

I have intense mood swings

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Star of BethlehemBalanced Outcome: Neutralize the effects of the trauma, whether immediate or delayed.

I feel devastated due to a recent shock

I am withdrawn due to traumatic events in my life

I have never recovered from loss or fright

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Sweet ChestnutBalanced Outcome: Liberation from despair and despondency. Peace of mind and faith that all is good

I feel extreme mental or emotional heartache

I have reached the limits of my endurance

I am in complete despair, all hope gone

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VervainBalanced Outcome: Calm, wise and tolerant. Able to relax and take broad view of life and events.

I get high-strung and very intense

I try to convince others of my way of thinking

I am sensitive to injustice, almost fanatical

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VineBalanced Outcome: Determination without domination. See the good in others/encourage.

I tend to take charge of projects, situations, etc.

I consider myself a natural leader

I am strong-willed, ambitious and often bossy

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WalnutBalanced Outcome: Ability to move forward and remain steadfast to one's path in life.

I am experiencing change in my life--a move, new job, etc.

I get drained by people or situations

I want to be free to follow my own ambitions

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Water VioletBalanced Outcome: Warmer relationships with others, while maintaining one's wisdom.

I give the impression that I'm aloof

I prefer to be alone when overwhelmed

I often don't connect with people

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White ChestnutBalanced Outcome: Peace of mind, the head is clear and thinking is under control.

I am constantly thinking unwanted thoughts

I relive unhappy events or arguments over and over again

I am unable to sleep at times because I can't stop thinking

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Wild OatBalanced Outcome: I picture of what to do in life with positive ideas and ambitions.

I can't find my path in life

I am drifting in life and lack direction

I am ambitious but don't know what to do

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Wild RoseBalanced Outcome: Lively interest in life, work and the world in general.

I am apathetic and resigned to whatever happens

I have the attitude, "It doesn't matter anyhow"

I feel no joy in life

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WillowBalanced Outcome: Allows people to forgive and forget past injustices and enjoy life.

I feel resentful and bitter

I have difficulty forgiving and forgetting

I think life is unfair and have a "Poor me attitude"

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Vibrational Essences (Bach Flower Essences and other essences) do not replace qualified medical assistance if you have a physical illness or disease, however, they will complement and help that treatment on subtle levels.

Please select to confirm you read above.

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CONGRATULATIONS

You just took the first step to a happier you!

You will receive an email after you click the Submit button below, to purchase your Bach Flower Essences Blend.

What does the purchase include:

* I will evaluate your Questionnaire

* You will receive your Personal Blend by mail, if not local.

* I will also make a short video for you to keep that explains the Bach Flower Essences Blend and why I selected the flowers I did. Hopefully, this answers all your questions you may have.

*You will be able to come back to the video once a month to update your progress and your flowers.

*I will be here to support you on your journey with the Bach Flower Essences

Don't forget to hit Submit below.

Wishing you SimplyWellness!

Stephanie