The following questionnaire was developed from the original writings of Dr. Edward Bach and is provided for your interest and self-assessment. Please print out and read and answer each of the questions carefully. After completing the Questionnaire in full, refer to the answer key at the bottom of page. Check only those questions for which you gave a definite YES answer. If your answer is NO or SOMETIMES, leave the box blank.
IMPORTANT NOTICE We make no claims as to the effectiveness of the Bach Essences on the conditions described in the Questionnaire. Persistent conditions and those conditions requiring medical attention should be referred to a physician immediately.
( ) 1. Do you have vague fears which you cannot explain?
( ) 2. Do you often find yourself distressed and anxious, but are unable to put your finger on the problem?
( ) 3. Do you wake with a sense of apprehension and foreboding, feeling that something bad may happen, but don't know what it may be?
( ) 4. Do you have specific fears which you can identify and would like to overcome?
( ) 5. Are you shy and easily frightened by particular circumstances and things?
( ) 6. When faced with situations or things that frighten you, do you become nervous and too paralyzed to act?
( ) 7. Do you fear losing control of your mind or body?
( ) 8. Are you compulsive, or have impulses to do things you know are wrong but have difficulty controlling your actions?
( ) 9. Do you fear losing control and hurting yourself or others?
( ) 10. Do you worry over the health and safety of your friends and family?
( ) 11. Do you fear that something may happen to those close to you?
( ) 12. Does your over-concern and worry for others cause you considerable distress?
( ) 13. Do you suffer from extreme terror?
( ) 14. Do you tend to panic and become hysterical?
( ) 15. Are you troubled by nightmares?
( ) 16. Do you lack confidence in your ability to judge things on your own and make decisions?
( ) 17. Do you find yourself asking other people's advice, even when you know what you want?
( ) 18. After taking advice from others, do you find yourself confused by the choices, constantly changing your direction according to the latest recommendations?
( ) 19. Do you suffer from indecision, uncertainty or hesitancy?
( ) 20. Do you have difficulty choosing between one thing and another?
( ) 21. Do you experience extreme mood swings, or have difficulty in keeping your balance?
( ) 22. Are you dissatisfied with your current role in life, feeling that life is passing you by?
( ) 23. Have you tried many different directions in life, but nothing seems to bring satisfaction?
( ) 24. Would you like to find a new lifestyle, career or change your old one, but have difficulty deciding what you should be doing?
( ) 25. Do you lack confidence?
( ) 26. Do you not try things for fear of failing?
( ) 27. Do you feel inferior, and that others are more capable and qualified than you?
( ) 28. On rising in the morning, do you find yourself tired, not wanting to get up?
( ) 29. Do you feel some part of you needs to be strengthened before you can tackle the day?
( ) 30. Do you find once you have started your daily activities your tiredness is forgotten, and you're able to complete your task?
( ) 31. Are you absentminded, or does your attention easily wander, making it difficult to concentrate?
( ) 32. Do you find you have little interest in present circumstances, often daydreaming, wishing you were somewhere else?
( ) 33. Do you find yourself dozing off frequently, regardless of where you are?
( ) 34. Do you find you are caught between living in the present and dwelling in memories of the past?
( ) 35. Are there things you would like to have done with your life but never had the opportunity to do?
( ) 36. Do you find yourself reminiscing about the good old days, wishing you were able to live your life over again?
( ) 37. Do you find you are indifferent and apathetic toward life?
( ) 38. Are you resigned to your current circumstances, making little effort to improve things or find joy?
( ) 39. Do you feel you've given up and don't care one way or another what happens?
( ) 40. Do you find you can't sleep because your thoughts give you no rest?
( ) 41. Do you find your head full of persistent, unwanted thoughts that prevent concentration?
( ) 42. Do you relive unhappy event or arguments over and over again?
( ) 43. Do you find you don't learn from past experiences, repeating the same mistakes or patterns of behavior?
( ) 44. Due to lack of observation, do you find it necessary to go over things already done?
( ) 45. Is there a particular situation or condition continually recurring in your life which you would like to overcome?
( ) 46. Are you now going through, or have you recently gone through, an illness or personal ordeal which left you physically and mentally drained?
( ) 47. Do you tire easily with no reserve energy to complete your tasks or enjoy the day?
( ) 48. Do you feel sapped of strength and vitality, where even the least effort exhausts you?
( ) 49. Do others find you aloof, prideful and at times condescending?
( ) 50. Do you keep to yourself, not wishing to be interfered with or to interfere in other people's affairs?
( ) 51. Are you self-reliant? Do you prefer spending your time alone?
( ) 52. Do you find yourself losing patience, becoming tense and irritable with people and things that move too slowly for you?
( ) 53. Do you do things in a rush, racing from one place or situation to another?
( ) 54. Do you find you need to work alone, because others can't keep up to your pace?
( ) 55. Do you find others avoiding conversation with you because you tend to talk a great deal?
( ) 56. Do you dislike being alone and seek the company of anyone willing to listen to your troubles?
( ) 57. Do you feel the need to steer conversations back to your special interests or problems? Are you reluctant to discontinue them even when the listener has to leave?
( ) 58. When worried or in pain, do you tend to conceal it from others, making light of even the most trying of circumstances?
( ) 59. Do you go out of your way to avoid burdening others with your problems, giving in to the wishes of others in order to avoid an argument or quarrel?
( ) 60. When troubled, do you find yourself drinking alcohol, or using stimulants or drugs to assist in keeping up a happy disposition?
( ) 61. Are you easily imposed on because of your willingness to help others?
( ) 62. Is it difficult for you to say no when you're asked for help, becoming more a servant than a willing helper?
( ) 63. Do you neglect your own needs, because you are too busy taking care of other people's needs?
( ) 64. Are you involved in a relationship or situation you would like to be free of, but cannot break away from?
( ) 65. Are you currently in a state of transition or change?
( ) 66. In the midst of this change, do you find that you're having difficulty in letting go of past attachments or in starting new beginnings?
( ) 67. Are you suspicious and mistrusting of other people's motives and intentions?
( ) 68. Do others find you spiteful, envious, jealous or vengeful?
( ) 69. Do you find yourself lacking compassion or warmth toward others?
( ) 70. Are you rarely content with your accomplishments, feeling that you could always do better?
( ) 71. Do you blame yourself for other people's mistakes, feeling that their shortcoming are in some way your fault or responsibility?
( ) 72. Are you hard on yourself when you fail to live up to the standards or expectations you've set for yourself?
( ) 73. Do you tend to overextend your commitments?
( ) 74. Do you find yourself overwhelmed by your work, and despite being capable feel you have taken on more than you can do?
( ) 75. Do you become despondent when faced with the magnitude of your responsibilities?
( ) 76. Have there been past traumas or shocks in your life, which you may not have completely recovered from?
( ) 77. Do you feel a past surgery or accident is responsible for your present condition?
( ) 78. Have you recently, or in the past, suffered a personal loss which you haven't quite gotten over?
( ) 79. Do you feel you've reached the limits of your endurance, and there's nothing but annihilation left to face?
( ) 80. Do you suffer from mental anguish and deep despair?
( ) 81. Do you feel that the burden of life is more than you can bear?
( ) 82. Have you lost hope that you will recover from or be helped in overcoming an illness or difficulty?
( ) 83. Do you feel it is useless to seek further help for your problem?
( ) 84. Have you given up hope that things will change for the better in some circumstance or situation in your life?
( ) 85. Do you ever become gloomy and depressed for no known reason?
( ) 86. Does this depression envelope you like a dark cloud, hiding the joy of life?
( ) 87. Do you find this gloom and depression, for no apparent reason, lifts as suddenly as it comes?
( ) 88. Are you easily discouraged when things don't go your way?
( ) 89. When setting out to accomplish a task, do you become over-sensitive to small delays or hindrances which may lead to self-doubt, and at times to depression?
( ) 90. Is it hard for you to start over again once you've encountered difficulties?
( ) 91. Are you one who tirelessly struggles on despite oppositions and delays?
( ) 92. Can you always be depended on to complete what you set out to do, regardless of the challenge?
( ) 93. Do you tend to throw yourself into your projects neglecting your own needs, as well as the needs of those close to you?
( ) 94. Through no fault of your own, do you feel that life has been unfair or unjust to you?
( ) 95. Have you become resentful and bitter toward those who may have treated you poorly?
( ) 96. Despite all you have done, do you feel your best efforts have largely gone unrewarded, while others not as deserving as yourself, have gained?
( ) 97. Do you feel unclean or ashamed over an act you should not have committed, or over someone or something have violated you personally?
( ) 98. Do you find yourself preoccupied with small physical problems suc
( ) as pimples, small blemishes or rashes, while overlooking more serious conditions?
( ) 99. Do you feel there is something wrong with, or some things you would like changed, in your physical appearance?
( ) 100. Are you compulsive about cleanliness, even at times to the extreme?
( ) 101. Are you afraid of becoming, or feel you have already become, contaminated and need to be cleansed?
( ) 102. Are you possessive of those close to you and feel you know what's best for them, often directing and correcting even small details of their lives?
( ) 103. Do you feel you are not appreciated by those you care for?
( ) 104. Do you find yourself needing the attention and devotion of those you love, feeling it's their duty to stay in close contact with you?
( ) 105. When assessing people and situations, do you look for what you can find wrong?
( ) 106. Do the small habits and idiosyncracies of others bother you?
( ) 107. Are you critical and intolerant of those who don't measure up to your standards or expectations?
( ) 108. Do you have strong opinions which you attempt to convince others are right?
( ) 109. Are you easily incensed by injustices, arguing for and defending principles which you believe in?
( ) 110. Are you high-strung, at times tense and over-enthusiastic, always teaching and philosophizing?
( ) 111. Do you feel you have a mission in life to conform with or live up to?
( ) 112. Are you strict in your adherence to a religious or social discipline, or in a particular way of living?
( ) 113. Do you feel it's important to make an example of yourself by living up to your ideals, so that others may follow?
( ) 114. Do you tend to take charge in circumstances and situations you're involved with?
( ) 115. Are you strong-willed and expect complete obedience (without question) from those around you?
( ) 116. Do you consider yourself a "born leader?"
ANSWER KEY Count the number of checks (for YES ANSWERS) in each of the given question groupings (example 1-3). If there are two or more Yes answers in a question group, put a check next to that Essence. Then refer to our catalog for a detailed description of each of the Essences you have checked. Select by priority the Essences you feel you need most. Remember up to six Essences may be combined and taken at one time. No more than six to eight. This questionnaire is meant for your personal confidential use and should be referred to when ordering. Please keep this completed questionnaire in your possession.
|19-21||Scleranthus||76-78||Star of Bethlehem|
|22-24||Wild Oat||79-81||Sweet Chestnut|
|40-42||White Chestnut||97-101||Crab Apple|
Beyond the Rainbow