Confidential Questionnaire

for bach therapy

Check the Yes radio button ONLY if the statement applies to you at this specific time in your life.

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QUESTIONS

ONLY CHECK THE BUTTON IF THE ANSWER IS YES. OTHERWISE, IGNORE THE ANSWERS.

1-3

Do you have fears which you cannot explain?
yes
Do you often find yourself distressed and anxious, but are unable to put your finger on the problem?
Yes
Do you wake with a sense of apprehension and foreboding, feeling that something bad may happen, but don’t know what it may be?
Yes

4-6

Do you have specific fears you can identify and would like to overcome?
Yes
Are you shy and easily frightened by particular circumstances and things?
Yes
When faced with situations or things that frighten you, do you become nervous and too paralyzed to act?
Yes

7-9

Do you fear losing control of your mind or body?
Yes
Are you compulsive, or have impulses to do things you know are wrong but have difficulty controlling your actions?
Yes
Do you fear losing control and hurting yourself or others?
Yes

10-12

Do you worry over the health and safety of your friends and family?
Yes
Do you fear that something may happen to those close to you?
Yes
Does your over-concern and worry for others cause your considerable distress?
Yes

13-15

Do you suffer from extreme terror?
Yes
Do you tend to panic and become hysterical?
Yes
Are you troubled by nightmares?
Yes

16-18

Do you lack confidence in your ability to judge things on your own and make decisions?
Yes
Do you find yourself asking other people’s advice, even when you know what you want?
Yes
After taking advice from others, do you find yourself confused by the choices, constantly changing your direction according to the latest recommendation?
Yes

19-21

Do you suffer from indecision, uncertainty or hesitancy?
Yes
Do you have difficulty choosing between one thing and another?
Yes
Do you experience extreme mood swings, or have difficulty in keeping your balance?
Yes

22-24

Are you dissatisfied with your current role in life, feeling that life is passing you by?
Yes
Have you tried many different directions in life, but nothing seems to bring satisfaction?
Yes
Would you like to find a new lifestyle, career or change your old one, but have difficulty with deciding what you should be doing?
Yes

25-27

Do you lack confidence?
Yes
Do you not try things for fear of failing?
Yes
Do you feel inferior, and that others are more capable and qualified than you?
Yes

28-30

On rising in the morning, do you find yourself tired, not wanting to get up?
Yes
Do you feel some part of you needs to be strengthened before you can tackle the day?
Yes
Do you find once you have started your daily activities your tiredness is forgotten, and you’re able to complete your task?
Yes

31-33

Are you absentminded, or does your attention easily wander, making it difficult to concentrate?
Yes
Do you find you have little interest in present circumstances, often daydreaming, wishing you were somewhere else?
Yes
Do you find yourself dozing off frequently, regardless of where you are?
Yes

34-36

Do you find you are caught between living in the present and dwelling in memories of the past?
Yes
Are there things you would like to have done with your life but never had the opportunity to do?
Yes
Do you find yourself reminiscing about the good old days, wishing you were able to live life over again?
Yes

37-39

Do you find you are indifferent and apathetic toward life?
Yes
Are you resigned to your current circumstances, making little effort to improve things or find joy?
Yes
Do you feel you’ve given up and don’t care one way or another what happens?
Yes

40-42

Are you troubled by persistent unwanted thoughts?
Yes
Do you worry or have mental arguments which circle round in your head?
Yes
Do you have difficulty sleeping due to mental chatter and worries?
Yes

43-45

Do you find you don’t learn from past experiences, repeating the same mistakes or patterns of behavior?
Yes
Due to lack of observation, do you find it necessary to go over things already done?
Yes
Is there a particular situation or condition continually recurring in your life which you would like to overcome?
Yes

46-48

Are you now going through, or have you recently gone through, illness or personal ordeal which left you physically and mentally drained?
Yes
Do you tire easily with no reserve energy to complete your tasks or enjoy the day?
Yes
Do you feel sapped of strength and vitality, where even the least effort exhausts you?
Yes

49-51

Do others find you aloof, prideful and at times condescending?
Yes
Do you keep to yourself, not wishing to be interfered with or to interfere in others people’s affairs?
Yes
Are you self-reliant and prefer spending your time alone?
Yes

52-54

Do you find yourself losing patience, becoming tense and irritable with people and things that move too slowly for you?
Yes
Do you do things in a rush, racing from one place or situation to another?
Yes
Do you find you need to work alone, because others can’t keep up your pace?
Yes

55-57

Do you find others avoiding conversation with you because you tend to talk a great deal?
Yes
Do you dislike being alone and seek the company of anyone willing to listen to your troubles?
Yes
Do you feel the need to steer conversations back to your special interests or problems, and are reluctant to discontinue them even when the listener has to leave?
Yes

58-60

When worried or in pain, do you tend to conceal it from others, making light of even the most trying of circumstances?
Yes
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?
Yes
When troubled, do you find yourself drinking alcohol or using stimulants or other drugs to assist in keeping up a happy disposition?
Yes

61-63

Are you easily imposed on because of your willingness to help others?
Yes
Is it difficult for you to say no when you’re asked for help, becoming more a servant than a willing helper?
Yes
Do you neglect your own needs, because you are too busy taking care of other people’s needs?
Yes

64-66

Are you involved in a relationship or situation that you would like to be free of, but cannot break away?
Yes
Are you currently in a state of transition or change?
Yes
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?
Yes

67-69

Are you suspicious and mistrusting of other people’s motives and intentions?
Yes
Do others find you spiteful, envious, jealous or vengeful?
Yes
Do you find yourself lacking compassion or warmth towards others?
Yes

70-72

Are you rarely content with your accomplishments, feeling that you could always do better?
Yes
Do you blame yourself or other’s mistakes, feeling that their shortcomings are in some way your fault or responsibility?
Yes
Are you hard on yourself with you fail to live up the standards or expectations that you’ve set for yourself?
Yes

73-75

Do you tend to overextend your commitments?
Yes
Do you find yourself overwhelmed by your work, and despite being capable fee you have taken on more than you can do?
Yes
Do you become despondent when faced with the magnitude of your responsibilities?
Yes

76-78

Have there been past traumas or shocks in your life, which you may not have completely recovered from?
Yes
Do you feel a past surgery or accident is responsible for your present condition?
Yes
Have you recently, or in the past, suffered personal loss which you haven’t quite gotten over?
Yes

79-81

Do you feel you’ve reached the limits of your endurance, and there’s nothing but annihilation left to face?
Yes
Do you suffer from mental anguish and deep despair?
Yes
Do you feel that the burden of life is more than you can bear?
Yes

82-84

Have you lost hope that you will recover from or be helped in overcoming an illness or difficulty?
Yes
Do you feel it is useless to seek further help for your problems?
Yes
Have you given up hope that things will change for the better in some circumstance or situation in your life?
Yes

85-87

Do you ever become gloomy and depressed for no known reason?
Yes
Does this depression envelope you like a dark cloud, hiding the joy of life?
Yes
Do you find this gloom and depression, for no apparent reason, lifts as suddenly as it comes?
Yes

88-90

Are you easily discouraged when things don’t go your way?
Yes
When setting out to accomplish a task, do you become over-sensitive to small delays and hindrances, which may lead to self-doubt, and at times to depression?
Yes
Is it hard for you to start over again once you’ve encountered difficulties?
Yes

91-93

Are you one who tirelessly struggles on despite oppositions and delays?
Yes
Can you always be depended on to complete what you set out to do?
Yes
Do you tend to throw yourself into your projects neglecting your own needs, as well as the needs of those close to you?
Yes

94-96

Through no fault of your own, do you feel that life has been unfair or unjust to you?
Yes
Have you become resentful and bitter toward those who may have treated you poorly?
Yes
Despite all you have done, do you feel your best efforts have largely gone unrewarded, while others not as deserving as yourself, have gained?
Yes

97-101

Do you feel unclean or ashamed over an act you should not have committed, or over someone or something having violated you personally?
Yes
Do you find yourself preoccupied with small physical problems such as pimples, small blemishes or rashes, while overlooking more serious conditions?
Yes
Do you feel there is something wrong with, or some things you would like changed, in your physical appearance?
Yes
Are you compulsive about cleanliness, even at times to the extreme?
Yes
Are you afraid of becoming, or feel you have already become contaminated and need to be cleansed?
Yes

102-104

Are you possessive of those close to you and feel you know what’s best for them often directing And directing and correcting even small details of their lives?
Yes
Do you feel you are not appreciated by those you care for?
Yes
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?
Yes

105-107

When assessing people and situations, do you look for what you can find wrong?
Yes
Do the small habits and idiosyncrasies of others bother you?
Yes
Are you critical and intolerant of those who don’t measure up to your standards or expectations?
Yes

108-110

Do you have strong opinions which you attempt to convince others are right?
Yes
Are you easily incensed by injustices, arguing for and defending principles which you believe in?
Yes
Are you high-strung, at times tense and over-enthusiastic, always teaching and philosophizing?
Yes

111-113

Do you feel you have a mission in life to conform with or live up to?
Yes
Are you strict in your adherence to a religious or social discipline, or in a particular way of living?
Yes
Do you feel it’s important to make an example of yourself by living up to your ideals, so that others may follow?
Yes

114-116

Do you tend to take charge in circumstances and situations you’re involved with?
Yes
Are you strong-willed and expect complete obedience (without question) from those around you?
Yes
Do you consider yourself a “born leader”?
Yes

DISCLAIMER:

We make no claims as to the effectiveness of the Bach Remedies on the conditions described in the questionnaire. Persistent conditions and those conditions requiring medical attention should be attended to by a physician immediately.

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