Bach Flower Questionnaire

Bach Flower Questionnaire

The Original Bach Flower Remedies is a natural system of healing.
Name*

First NameLast Name
Email*
example@example.com
Mobile Phone Number*

Country CodePhone Number
Please explain the reasons why you decided to start Bach Flowers Therapy (Be as specific as possible):*
INSTRUCTIONS

1. Read each statement and tick EACH that describes how you feel RIGHT NOW. You can tick none or any boxes for each essences.

2. Submit.

3. You will receive an email with a copy of your submited form.

4. Bodywave will get back to you shortly for the next steps.
AGRIMONY

I often hide my feelings behind a facade of cheerfulnessI dislike arguments and often give in to avoid conflictI turn to food, work, alcohol, drugs, etc. when down
ASPEN

I feel anxious without knowing whyI have a strange fear that something bad will happenI wake up feeling anxious
BEECH

I easily get annoyed by the habits of othersI often focus on others people’s mistakesI find myself being critical and intolerant of others
CENTAURY

I often neglect my own needs to please othersI find it difficult to say "no"I tend to be easily influenced
CERATO

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

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

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

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

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

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

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

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

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

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

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

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
HORNBEAM

I often feel too tired to face the day aheadI feel mentally exhaustedI tend to put things off and may procrastinate
IMPATIENS

I find it hard to wait for thingsI am impatient and irritableI prefer to work alone
LARCH

I lack self-confidenceI feel inferior and often become discouragedI never expect anything but failure
MIMULUS

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

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

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
OLIVE

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
PINE

I feel unworthy and inferiorI often feel guiltyI blame myself for everything that goes wrong
RED CHESTNUT

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
ROCK ROSE

I sometimes feel terror and panicI become helpless and frozen when afraidI suffer from nightmares
ROCK WATER

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

I find it difficult to make decisions when I have 2 optionsI often change my opinionsI have intense mood swings
STAR OF BETHLEHEM

I feel devastated due to a recent shockI am withdrawn due to traumatic events in my lifeI have never recovered from loss, trauma or fright
SWEET CHESTNUT

I feel extreme mental or emotional heartacheI have reached the limits of my enduranceI feel complete despair, all hope gone
VERVAIN

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

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

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
WATER VIOLET

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

I have repeated unwanted thoughts and worriesI relive unhappy events or arguments over and over againI am unable to sleep at times because I can't stop thinking
WILD OAT

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

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

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

I have experienced a traumaI feel very stressed outI feel irritated and impatientI feel un-grounded and spaceyI feel frighted and frozenI feel I may lose self-control
How was your experience with this questionnaire?
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