Bach Flower Remedies Blend Self-Assessment Questionnaire

Bach Remedies Assessment Questionnaire

Completing this questionnaire will help me design the right remedy blend for you.

For each question, mark as many options as applies to you. If a statement is not applicable to you, please leave it blank.

Once you remedy is ready, I will contact you to collect it. Flower remedies are completely herbal, no contra indication.

Once you receive your blend, use 4 drop sublingually, or in hot or cold drink; three times a day. You should experience or feel a difference within days.

Once your bottle(s) is finished, you can complete this questionnaire again and it will let us know how things have shifted and whether you need to continue with a new blend.

Life Can Only Get Better!

Date*

Date

Date Of Birth*

Date

Name*

First NameLast Name

Email*

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Phone Number*

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1

I hide my feelings behind a facade of cheerfulnessdislike arguments and often give in to avoid conflictIturn to food, work, alcohol, drugs, etc. when down

2

I feel anxious without knowing whyI have a secret fear that something bad will happenIwake up feeling anxious

3

I get annoyed by the habits of othersfocus on others' mistakes II am critical and intolerant

4

I often neglect my own needs to pleaseI find it difficult to say "noI tend to be easily influenced

5

I constantly second-guess myselfI seek advice, mistrusting my own intuitionI often change my mind out of confusion

6

I'm afraid I might lose control of myselfI have sudden fits of rageI feel like I'm going crazy

7

I make the same mistakes over and overI don't learn from my experienceI keep repeating the same patterns

8

I need to be needed and want my loved ones closeI feel unloved and unappreciated by my familyI easily feel slighted and hurt

9

I often feel spacey and absent mindedI find myself unable to concentrate for longI get drowsy and sleep more than necessary

10

I am overly concerned with cleanlinessI feel unclean or physically unattractiveI tend to obsess over little things

11

I feel overwhelmed by my responsibilitiesI don't cope well under pressureIhave temporarily lost my self-confidence

12

I become discouraged with small setbacksI am easily disheartened when faced with difficultiesI am often skeptical and pessimistic

13

I feel hopeless, and can't see a way outI lack faith that things could get better in my lifeI feel sullen and depressed

14

I am obsessed with my own troublesI dislike being alone and I like to talkI usually bring conversations back to myself

15

Iam suspicious of othersI feel discontented and unhappyI am full of jealousy, mistrust, or hate

16

I'm often homesick for the "way it wasI think more about the past than the presentI often think about what might have been

17

I often feel too tired to face the day aheadfeel mentally exhaustedI tend to put things off

18

I find it hard to wait for thingsIam impatient and irritableIprefer to work alone

19

Ilack self-confidenceIfeel inferior and often become discouragedI never expect anything but failure

20

I am afraid of things such as spiders, illness, etc.I am shy, overly sensitive, and modestI get nervous and embarrassed

21

I get depressed without any reasonI feel my moods swinging back and forthI get gloomy feelings that come and go

22

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

23

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

24

Ifeel unworthy and inferioroften feel guiltyI blame myself for everything that goes wrong

25

I am overly concerned and worried about my loved onesam distressed and disturbed by other people's problemsI worry that harm may come to those I love

26

I sometimes feel terror and panicbecome helpless and frozen when afraidsuffer from nightmares

27

I set high standards for myselfI am strict with my health, work &/or spiritual disciplineI am very self-disciplined, always striving for perfection

28

I find it difficult to make decisionsI often change my opinionsI have intense mood swings

29

I feel devastated due to a recent shockI am withdrawn due to traumatic events in my lifehave never recovered from loss or fright

30

I feel extreme mental or emotional heartacheIhave reached the limits of my enduranceI am in complete despair, all hope gone

31

I get high-strung and very intenseI try to convince others of my way of thinkingI am sensitive to injustice, almost fanatical

32

I tend to take charge of projects, situations, etc.I consider myself a natural leaderIam strong-willed, ambitious and often bossy

33

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

34

I give the impression that I'm aloofI prefer to be alone when overwhelmedI often don't connect with people

35

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

36

I can't find my path in lifeI am drifting in life and lack directionI am ambitious but don't know what to do

37

I am apathetic and resigned to whatever happensI have the attitude, "It doesn't matter anyhowIfeel no joy in life

38

I feel resentful and bitterI have difficulty forgiving and forgettingI think life is unfair and have a "Poor me attitude

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Custom blends heal and dissolve conflict between your action and how you feel and your outlook.