Emotional-Health-Questionnaire by hedongchenchen


									 Emotional Health Assessment
Name:                                                                                            Date:
  Tel:                                                                                    Practitioner: Anne-Marie Martin

         This questionnaire will help to provide insight into your personality, mood, and emotional outlook. Consideration
         of these aspects of a person's nature is of utmost importance because disharmony within oneself is the root cause
         of disease. If the emotional balance is corrected, the body's natural ability to throw off illness can be strengthened.
         Based on this questionnaire, a specific remedy can be formulated using Bach Flower Essences that are indicated
         according to your current emotional needs, as well as your particular temperament, state of mind, and natural
         character. The Bach Essences are a gentle and subtle means of restoring peace of mind and thus allowing the
         body, and the being as a whole, a chance to regain its strength and ability to combat ill health through its own
         natural healing processes. We urge you to look closely and honestly at yourself when answering the questions.
         This will ensure that the combination of essences chosen (based on these answers) will assist you in bringing about
         the inner harmony necessary for complete balance. It is important to refrain from making judgments about your
         observations. Virtually every human being experiences emotional conflict and the first step towards healing is to
         become aware of our feelings and needs. Rest assured that this is a safe, confidential and non-judgmental place
         where you can express yourself freely.

         Instructions: Read the following descriptions and rate them from 0 to 9 (0 means that you do not experience this
         emotion, while a 9 means that you experience this emotion strongly). When reading the essence descriptions, it
         may seem as if very many apply to you. However, as a formula should not contain more than 5 or 6 essences, once
         you have rated the descriptions that apply to you, you may need to review and prioritize the ones that resonate
         most with you at this time. If you check all three questions for a particular remedy, that remedy is highly indicated
         for you. If you feel strongly that many remedies are necessary for you, it is best to group them according to
         related issues and to prioritize them in order to formulate a group of essences that works toward a common goal.

                                                       Remedy                 Description                   Rating   Total     Indications
                                                                Are you distressed by arguments and
                                                                quarrels, often "giving in" to avoid any
                                                                                                                                   Helps you
                                                                conflict?                                                     communicate your
                                                                Do you find yourself hiding your worries                      true feelings rather
                                                                behind a cheerful, smiling face in an                            than hide them
                                                    Agrimony    attempt to conceal your pain from                     0         behind a cheerful
                                                                others?                                                        face or to seek an
                                                                                                                                escape or turn to
                                                                When you feel life’s pressures weighing
                                                                                                                             outside influences to
                                                                you down, do you often turn to alcohol or                        help you cope.
                                                                to drugs or other outside influences to
         Over-sensitivity to ideas and influences

                                                                help you cope?
                                                                Are you unable to say no to those who
                                                                constantly impose upon your good
                                                                nature?                                                      Helps you take care
                                                                                                                              of your own needs
                                                                Do you often deny your own needs in
                                                    Centaury    order to please others?
                                                                                                                      0      and assert yourself if
                                                                                                                              you find it hard to
                                                                Do you tend to be timid and shy, easily                        say no to others
                                                                influenced by those stronger nature than
                                                                Are you full of jealousy, envy, or hate?                     Encourages a more
                                                                Do you feel generalized anger toward                          generous nature
                                                                other people?                                                   when you feel
                                                    Holly                                                             0       jealous, envious,
                                                                                                                                 vengeful or
Over-sensitivity to
                                                                                       Encourages a more
                                                                                        generous nature
                                                                                          when you feel
                      Holly                                                        0    jealous, envious,
                                     Do you mistrust others’ intentions, feeling           vengeful or
                                     that people have "ulterior motives"?                  suspicious.

                                     Are you distracted by outside influences?

                                     Are you experiencing any change in your            Allows you to make
                                                                                       or adapt to major life
                                     life–a move, new job, loss of a loved one,
                                                                                       changes and to fulfill
                      Walnut         new relationship, divorce, puberty,           0    your ambitions free
                                     menopause, or giving up an addiction?             from the influence of
                                     Do you need to make a break from
                                     strong forces or attachments in your life
                                     that may be holding you back?
                                     Do you awaken with a sense of fear and
                                     anxiety of what the day will bring?                   Replaces
                                     Do you have feelings of apprehension,             apprehension and
                      Aspen          anticipation, or uneasiness with no           0   vague fears with a
                                     known causes?                                      sense of security
                                                                                       and peace of mind.
                                     Do you worry that something bad may
                                     happen but you are not sure what?
                                     Are you afraid of hurting yourself or                 Helps you act
                                     others?                                            rationally and think
                                     Do you fear losing control of yourself?            clearly with a calm
                      Cherry Plum                                                  0    and balanced mind
                                     Do you have tendency to act irrationally
                                     and violently, exploding into unexplained         when you fear losing
                                     fits of rage and anger?
                                     Are you shy, overly sensitive, and often
                                                                                        Brings courage and

                                     Do you have fears of known things, such
                                                                                        calm to face things
                                     as illness, death, pain, heights, darkness,
                      Mimulus        snakes, etc.?
                                                                                   0   that frighten or worry
                                                                                         you, also aids the
                                     When you are confronted with a                        shy and timid.
                                     frightening situation, do you become too
                                     paralyzed to act?
                                     Are you distressed and disturbed by
                                     other people’s problems?                          Allows you to love
                                     Are you excessively concerned and                  without anxiety or
                      Red Chestnut   worried for your loved ones?                  0    fear for the well-
                                     Do you constantly worry that harm may             being of your loved
                                     come to loved ones, family members, or
                                     others you care for?
                                     Do you become helpless and frozen in               Adds courage and
                                     the face of your fear?                            presence of mind in
                      Rock Rose      Do you feel terror and panic?
                                                                                   0   the face of terror or
                                     Do you suffer from nightmares?                       extreme fear.

                                     Are you often seeking advice and
                                     confirmation from other people,
                                     mistrusting your own wisdom?                      Instills decisiveness
                                     Do you change direction often, first going         when you question
                      Cerato         one way, then another because you lack        0   your own judgement
                                     the confidence in yourself to stick with            and ask other for
                                     one direction?                                            advice.
                                                                                      Instills decisiveness
                                                                                       when you question
                      Cerato                                                      0   your own judgement
                                                                                        and ask other for

                                    Do you constantly question your own
                                    decisions and judgment?
                                    Are you easily disheartened when faced
                                    with difficult situations?                         Inspires a positive
                                    Do you become discouraged and                      attitude when you
                      Gentian       depressed when things go wrong?               0   feel discouraged or
                                    Does your pessimism prevent you from              despondent due to
                                    making an effort to accomplish
                                    Do you believe that nothing can be done
                                    to relieve your pain and suffering?
                                    Do you feel despondent and hopeless, at              Encourages a
                                    the end of your rope both mentally and               brighter, more
                      Gorse         physically?                                   0   positive perspective
                                                                                      when you feel there
                                    Do you lack confidence that things will

                                                                                        is no hope left.
                                    get better in your life and therefore make
                                    no effort to improve your circumstances?
                                    Do you feel overworked or bored with                Restores energy
                                    your life?                                            when you are
                                    Do you lack enthusiasm and therefore                 mentally weary,
                      Hornbeam      tend to procrastinate?
                                                                                  0     procrastinate and
                                    Do you often feel too tired to face the day        doubt your ability to
                                                                                      face the task ahead.
                                    Do you find it difficult to decide when
                                    faced with a choice of two possibilities?
                                                                                       Allows you to make
                                    Do you lack concentration, always fidgety            decisions more
                      Scleranthus   and nervous?                                  0     easily when you
                                    Do your moods change from one                         cannot choose
                                                                                      between two options.
                                    extreme to another: joy to sadness,
                                    optimism to pessimism, laughing to
                                    Are you displeased with your lifestyle and
                                    feel dissatisfied with your achievements?             Helps you to
                                                                                      determine what to do
                                                                                       with your life, when
                      Wild Oat      Do you find yourself in a complete state      0    you are undecided
                                    of uncertainty over major life decisions?          about which path to
                                    Do you have ambition but feel that life is
                                    passing you by?
                                    Are you annoyed by the habits and
                                    shortcomings of others?
                                    Do you find yourself being overly critical          Helps you to be
                                                                                       more tolerant and
                                    and intolerant, usually looking for what
                      Beech         someone has done wrong?
                                                                                  0   see the positive in
                                                                                      others despite their
                                    Do you prefer to work or be alone                    imperfections.
                                    because the seeming foolishness of
                                    others irritates you?
                                    Are you possessive and manipulative of
                                    those you care for?                                Helps you let go of
e welfare of others

                                    Do you need to be needed?                          those you care for,
                      Chicory                                                     0   allowing them to lead
                                                                                          their own lives.
                                                                                                                    Helps you let go of

Over-care for the welfare of others
                                                                                                                    those you care for,
                                                 Chicory                                                       0   allowing them to lead
                                                                Do you often feel unloved and
                                                                unappreciated by the loved ones "after all             their own lives.
                                                                you have done for them"?
                                                                Are you inflexible in your approach to life,
                                                                always striving for perfection?
                                                                                                                    Helps you to enjoy
                                                                Are you overly concerned with diet,                   life's pleasures
                                                 Rock Water     exercise, work, and spiritual disciplines?     0   rather than stick too
                                                                                                                   rigidly to your ideals
                                                                Are you so rigid in your ideals that you            or personal habits.
                                                                deny yourself the simple pleasures of
                                                                Do you feel tense and highly strung?
                                                                                                                    Helps you to relax
                                                                Do you have strong opinions and only
                                                                                                                    when you are over
                                                 Vervain        yours are the right ones?                      0     enthusiastic or
                                                                Is your over-enthusiasm almost to the                strongly driven.
                                                                point of being fanatical?
                                                                Are you inflexible and feel you know                   Allows you to
                                                                more than anyone else?                             develop your natural
                                                                Do you feel the need to always to be                 leadership skills
                                                 Vine           right?
                                                                                                               0       without being
                                                                Do you tend to be domineering and                     domineering or
                                                                Do you fail to learn from your
                                                                Do you find yourself making the same                Helps you observe
                                                                mistakes over and over again such as                  your mistakes
                                                 Chestnut Bud   choosing the wrong type of partner or          0    objectively so you
                                                                staying in a job you dislike?                      can learn from them
                                                                                                                      and move on.
                                                                Does it take you longer to advance in
                                                                your life because you are slow to learn
                                                                from past mistakes?
                                                                Are you drowsy and listless, sleeping
                                                                more often than necessary?                         Helps you live more
                                                                                                                      actively in the
                                                                Do you find yourself preoccupied and
                                                                                                                   present rather than
                                                 Clematis       dreamy, unable to concentrate for any          0    in the future or in
                                                                length of time?                                      your own dream
                                                                Do you often feel spaced and out of                       world.
                                                                touch with the "real world"?
                                                                Are you dissatisfied with your
                                                                                                                       Helps you put
Insufficient interest in present circumstances

                                                                Are you unable to change present                   memories of the past
                                                                circumstances because you are always                    into proper
                                                 Honeysuckle    looking back and never forward?
                                                                                                               0     perspective if you
                                                                                                                   are feeling homesick
                                                                Do you find yourself living in the past,            or overly nostalgic.
                                                                nostalgic and homesick for the "way it
                                                                Do you feel deep gloom that seems to
                                                                quickly descend for no apparent reason
                                                                and lifts just as suddenly?                        Brings back joy and
                                                                                                                   cheerfulness when
                                                 Mustard        Do you feel depressed without knowing          0   gloom descends for
                                                                why?                                               no obvious reason.
Insufficient interest in pre
                                                                                               Brings back joy and
                                                                                               cheerfulness when
                               Mustard                                                     0   gloom descends for
                                                                                               no obvious reason.
                                            Do you feel your moods swinging back
                                            and forth?
                                            Are you totally drained of all energy with
                                            no reserves left to carry on?
                                                                                                Restores energy
                                            Do you feel utterly and completely                   when you are
                               Olive        exhausted, both physically and mentally?
                                                                                           0     physically and
                                                                                               mentally exhausted.
                                            Is everything an effort, does your life lack
                                            Are you unable to sleep at times because
                                            your mind seems to be cluttered with
                                            mental arguments that go round and                    Encourages a
                                            round?                                              peaceful and calm
                               White                                                           mind when thoughts
                                            Do you relive unhappy events or                0   and worries go round
                               Chestnut     arguments over and over again?                      and round in your
                                            Do you find your head full of persistent,                 head.
                                            unwanted thoughts that prevent
                                            Are you apathetic and resigned to                      Helps you feel
                                            whatever may happen in your life?                   interest and joy in
                                            Do you have the attitude, "I will just live         life when you feel
                               Wild Rose    with it"?
                                                                                           0       apathetic and
                                            Do you lack the motivation to improve the             resigned to the
                                                                                               situation you are in.
                                            quality of your life?
                                            Are you embarrassed and ashamed of
                                            yourself physically, finding yourself                Helps you accept
                                            unattractive?                                          your physical
                               Crab Apple   Are you obsessed with cleanliness?             0    imperfections and
                                            Do you tend to concentrate on small                feel better about the
                                                                                                   way you are.
                                            conditions such as pimples or marks,
                                            neglecting more serious problems?
                                            Are you often overwhelmed by your
                                            responsibilities?                                     Restores your
                                            Do you become depressed and                        normal strength and
                                                                                               optimism when you
                                            exhausted when faced with your
                               Elm          everyday commitments?
                                                                                           0     are temporarily
                                                                                                 overwhelmed or
                                                                                                   burdened by
                                            Do you feel inadequate when it comes to
                                            dealing with the tasks ahead of you?
                                            Are you sure that you will fail and                   Instills a greater
                                            therefore do not even attempt things?              sense of self-esteem
                               Larch        Do you feel inferior and often become          0       when you feel
                                            discouraged?                                        inferior, fear failure
                                                                                                or lack confidence.
                                            Do you lack self-confidence?
                                            Are you exhausted but feel the need to
                                            struggle on against all odds?
                                                                                               Allows the naturally
                                            Do you have a strong sense of duty and               strong to take a
Despondency or despair

                               Oak          dependability, carrying on no matter what      0    break rather than
                                            obstacles stand in your way?                       struggle on without
                                            Do you neglect your own needs to
                                            complete a task?
                                            Are you full of guilt and self-reproach?           Allows you to accept
                                                                                                 yourself and your
                                                                                                actions as they are
                               Pine                                                        0   rather than feel guilty
                                                                                               or blame yourself for
                                                                                                  the mistakes of
Despondency or de
                                                                                                     Allows you to accept
                                       Do you blame yourself for everything that                       yourself and your
                                       goes wrong, including the mistakes of                          actions as they are
                    Pine               others?                                                 0     rather than feel guilty
                                       Do you set overly high standards for                          or blame yourself for
                                                                                                        the mistakes of
                                       yourself, never satisfied with your
                                       Are you numbed or withdrawn as a result
                                       of recent traumatic events in your life?
                                                                                                      Softens the impact
                    Star of            Have you suffered a loss or grief that you
                                                                                               0       of shock, grief or
                    Bethlehem          have never recovered from?                                            fright
                                       Have you suffered a shock in your life
                                       such as an accident, loss of a loved one,
                                       terrible news, illness?
                                       Do you feel as though the future holds
                                       nothing for you?                                              Brings optimism and
                                                                                                     peace of mind when
                    Sweet              Do you feel that you have reached the
                                                                                               0     anguish overwhelms
                    Chestnut           limits of what you could possibly endure?                     you and you can find
                                                                                                         no way out.
                                       Do you suffer from extreme mental
                                       Do you feel life is unfair and find yourself
                                       taking less and less interest in the things                    Helps you forgive
                                                                                                      past injustices and
                                       you used to enjoy?
                    Willow             Do you feel resentful and bitter?
                                                                                               0      move on when you
                                                                                                       feel resentful and
                                       Do you have difficulty forgiving and                                   bitter.
                                       Are you totally self-absorbed, concerned                        Helps you listen to
                                       only about yourself and your problems                          and empathize with
                                       and ailments?                                                   others rather than
                    Heather            Do you dislike being alone, always                      0          being overly
                                       seeking the companionship of others?                              concerned and
                                                                                                      talkative about your
                                       Do you talk incessantly, not interested in
                                                                                                          own affairs.
                                       what anyone else has to say?
                                       Are you impatient and irritable with others
                                       who seem to do things too slowly for                           Helps you deal with

                                       you?                                                            slow situations or
                                                                                                       people with good
                    Impatiens          Do you feel a sense of urgency in                       0       humor rather than
                                       everything you do, always rushing to get                          impatience or
                                       through things?                                                     irritability.
                                       Do you prefer to work alone?
                                       Do you appear to others to be aloof and
                                                                                                     Helps you to develop
                                       overly proud?                                                 warmer relationships
                                       Do you bear your grief and sorrow in                           with others when
                    Water Violet       silence?                                                0         your pride or
                                       Do you have tendency to be withdrawn                             independence
                                                                                                      makes you appear
                                       and prefer to be alone when faced with
                                       too many distractions?

         Please return form to: annemarie@glowellness.com

                        Glow Acupuncture & Wellness Center│ 1008 Homer St. Suite #410 Vancouver, BC, V6B 2X1
                               t: 778-786-2517 │ e: annemarie@glowellness.com │ www.glowellness.com
t: 778-786-2517 │ e: annemarie@glowellness.com │ www.glowellness.com
Bach Flower Formula

  Remedy 1:

                   Remedy   Description







Rating Total   Title   Indications

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