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Bach Flower Essence Self-Assessment Questionnaire

Carefully selected Bach Flower Essences help to balance emotional health. It can be used in conjunction with any pharmaceuticals, herbs, oils or other therapies.

This questionnaire will help me to select which remedies are right for you (up to 6 remedies). Once complete I will make you your own personalized remedy for just $10. I can mail it to you or if your local I can schedule a time to pick it up.

If you have questions about Bach Flower Essences or anything else Natural Health related, feel free to reach out to me at desiree@modernhippie.org

Your Name * First Last
Everything is completely confidential and results are stored on my personal computer and password protected.
Date * MM / DD / YYYY
Email OR Phone Number *

Please use which ever form of communication works best for you.
Emotional Temperament Statements:

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 1-3

I have vague fears which I cannot explain. I often find myself distressed and anxious, but I'm unable to put my finger on the problem. I wake with a sense of apprehension and foreboding, feeling that something bad may happen but I don't know what it will be.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 4-6
I have specific fears I can identify and would like to overcome. I'm shy and easily frightened by particular circumstances and things. When faced with situations or things that frighten me, I become nervous and too paralyzed to act.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 7-9
I fear loosing control of my mind or body. I'm compulsive, or have impulses to do things that I know are wrong but I have difficulty controlling my actions. I fear losing control and hurting myself or others.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 10-12
I worry over the health and safety of my friends and family. I fear that something may happen to those close to me. My over-concern and worry for others causes me considerable distress.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 13-15
I suffer from extreme terror. I tend to panic and become hysterical. I'm troubled by nightmares.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 16-18
I lack confidence in my ability to judge things on my own and make decisions. I find myself asking other peoples advice, even when I know what I want. After taking advice from others, I find myself confused by the choices, constantly changing my mind according to the latest recommendation.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 19-21
I suffer from indecision, uncertainty or hesitation. I have difficulty choosing between one thing and another. I experience extreme mood swings or have difficulty in keeping my mood balanced.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 22-24
I'm dissatisfied with my current position in life, feeling that life is passing me by. I've tried many different jobs but nothing seems to bring me satisfaction. I would like to find a new career or change my old one, but I have difficulty deciding what I want to do.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 25-27
When I get up in the morning, I find myself tired, not wanting to work. I feel some part of me needs to be strengthened before I can tackle your job. I find once I've started working my tiredness is forgotten and I'm able to complete my task.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 28-30
I've lost hope that I will recover from or be helped in overcoming an illness or difficulty. I feel it's useless to seek further help for my problems. I've given up hope that things will change for the better in some circumstance or situation in my life.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 31-33
I'm easily discouraged when things don't go my way. When I'm setting out to accomplish a task, I become over-sensitive to small delays & hinderances which may lead to self doubt & depression. Is it hard for me to start over again once I have encountered difficulties.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 34-36
I sometimes become gloomy and depressed for no known reason. This depression will sometimes envelop me like a dark cloud, hiding the joy of life. I find this gloom and depression, for no apparent reason, lifts as suddenly as it comes.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 37-39
I'm absentminded or my attention easily wanders, making it difficult to concentrate. I find that I have little interested in present circumstances, often daydreaming, wishing I was somewhere else. I find myself dozing off frequently, regardless of where I am.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 40-42
I find I'm caught between living in the present and dwelling in the past. There are things I would liked to have done with my life but never had the opportunity to do. I find myself reminiscing about the good old days, wishing I was able to live my life over again.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 43-45
I find I'm apathetic and indifferent towards life. I'm resigned to my current circumstances, making little effort to improve things or find joy. I feel that I've given up and don't care what happens one way or another.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 46-48
I'm troubled by persistant unwanted thoughts. I worry or have mental arguments which circle around in my mind. I have difficulty sleeping due to mental chatter and worries.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 49-51
I find I don't learn from past experiences, repeating the same mistakes or patterns of behavior. Due to lack of observation, I find it necessary to go over things already done. There is a particular situation or condition continually recurring in my life that I would like to overcome.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 52-54
I'm currently going through, or have recently gone through, an illness or personal ordeal which left me physically and mentally drained. I tire easily with no reserve energy to complete my tasks or enjoy the day. I feel sapped of strength and vitality, where even the least effort exhausts me.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 55-57
Others find me aloof, prideful and at times condescending. I usually keep to myself, not wishing to interfere in other people's affairs. I'm self reliant and prefer spending my time alone.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 58-60
I find myself loosing patience, becoming tense and irritable with people and things that move too slowly for me. I generally do things in a rush, racing from one place or situation to another. I find I need to work alone because others can't keep up my pace.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 61-63
I find others avoiding conversations with me because I tend to talk a great deal. I dislike being alone and seek the company of anyone willing to listen to my troubles. I feel the need to steer conversations back to my interests or problems & are reluctant to disengage them even when my listener has to go.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 64-66
When worried or in pain, I tend to conceal it from others making light of even the most trying of circumstances. I go out of my way to avoid burdening others with my problems, giving in to the wishes of others in order to avoid an argument or quarrel. When troubled I find myself drinking alcohol or using stimulants or other drugs to assist in keeping up my happy disposition.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 67-69
I'm easily imposed on because of my willingness to help others. Is it difficult for me to say no when I are asked for help, becoming more a servant than a willing helper. I neglect my own needs, because I am too busy taking care of other people's needs.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 70-72
I'm involved in a relationship that I would like to be free of, but cannot break away from. I'm currently in a state of transition or change. In the midst of this change, I find that I'm having difficulty in letting go of past attachments or in starting new beginnings.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 73-75
I find myself feeling suspicious and mistrusting of other people's motives and intentions. I find myself feeling spiteful, jealous or vengeful. I find myself lacking compassion or warmth towards others.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 76-78
I am rarely content with my accomplishments, feeling that I could always do a better job. I blame myself for other peoples mistakes, feeling that their short comings are in some way my fault or responsibility. I'm hard on myself, when I fail to live up to the standards or expectations I've set for myself.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 79-81
I tend to overextend my work commitments. I find myself overwhelmed by work and despite being capable feel that I have taken on more than I can do. I become more despondent when faced with the magnitude of my responsibilities.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 82-84
There have been past traumas or shocks in your life, some I may not have completely recovered from. I feel that a past surgery or accident is responsible for my present condition. I recently, or in the past, suffered a personal loss which I haven't quite gotton over.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 85-87
I feel I've reached the limits of my endurance and there's nothing but annihilation left to face. I suffer from mental anguish or deep despair. I feel that the burden of life is more than I can bare.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 88-90
I tirelessly struggle on despite opposition and delays. I always can be depended on to complete what I've set out to do, regardless of the challenge. I tend to throw myself into me work, neglecting my needs, as well as the needs of those close to me.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 91-93
Through no fault of my own, I feel that life has been unfair or unjust to me. I've become resentful or bitter toward those who may have treated me poorly. Despite all I've done, I feel my best efforts have largely gone unrewarded, while others not as deserving as myself, have gained.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 94-98
I feel unclean or ashamed over an act I should not have done, or over someone or something having violated me personally? I find myself preoccupied with small physical problems such as pimples. There is something wrong with or there are things about my physical appearance that I would change. I am compulsive about cleanliness, even at times to the extreme. I am afraid of becoming or feeling I have already become contaminated and need to be cleaned.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 99-101
I lack confidence. I don't try things for the fear of failing. I feel inferior and that others are more capable and qualified than myself.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 102-104
I'm possessive of those close to me and feel I know what's best for them, often directing and correcting even small details of their lives. I feel I am appreciated by those I care for. I find myself needing the attention and devotion of those I love, feeling it's their duty to stay in close contact with me.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 105-107
When assessing people and situations, I look for what I can find wrong. Small habits and idiosyncrasies of others bother me. I'm critical and intolerant of those who don't measure up to my standards or expectations.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 108-110
I have strong opinions which I attempt to convince others are right. I am easily incensed by injustices, arguing for and defending the principles which I believe in. I'm high strung, at times tense and over-enthusiastic, always teaching and philosophizing.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 111-113
I feel I have a mission in life to conform to or live up to. I'm strict in my adherence to a religious or social discipline, or in a particular way of living. I feel it's important to make an example of myself by living up to my ideals so others may follow.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
Statements 114-116
I tend to take charge in circumstances and situations I'm involved with. I am strong-willed and expect complete obedience (without question) from those around me. When taken to extreme, I can become tyrannical and domineering.

Check All That Apply; Your first reaction is usually the correct one so try not to think too hard on these.
DISCLAIMER*

This information is intended to select flower essences to achieve emotional balance; if you have a medical condition please consult a professional in that field.
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Emotional Temperament Statements:

DISCLAIMER*