Evaluation
Form
DATE:_________
CLIENTS NAME:____________________AGE:_____SEX:_____
ADDRESS:____________________________________________
_____________________________________________________
_____________________________________________________
TELEPHONE:__________________________________________
PLEASE
CHECK THE SIX REMEDIES THAT MOST
APPLY TO YOU AND IN ORDER
OF PREVALENCE
1. Do you use alcohol, drugs, food,
or work to escape pain, meanwhile putting on a happy face? Do you find
it hard to share your inner-self?____
2. Do you experience panic attacks or
have feelings of anxiety?____
3. Are you intolerant or judgmental of
others?____
4. Do you allow others to take advantage
of you, and find it hard to say
no ?____
5. Do you feel incapable of making your
own decisions? Do you usually seek advice from others?____
6. Do you feel compulsive, obsessive, or
out of control?____
7. Do you repeat destructive patterns in
life?____
8. Are you overly possessive of others,
always demanding attention?____
9. Do you live in a fantasy world, trying
to escape reality ?____
10. Are you comfortable with the way you
look? Do you feel mentally and physically unclean?____
11. Are you overwhelmed by
responsibilities?____
12. Are you easily discouraged and know
why? Do you make mountains out of molehills?____
13. Do you feel hopelessness and despair?
Do you feel like just giving up?____
14. Do you feel unhappy when you are
alone? Do you feel the need to talk about yourself and your problems
to anyone who will listen?____
15. Do you feel hatred, jealousy, or
envy, especially when your not getting the love you
desire?____
16. Do you dwell on the past, past loves,
or ambitions?____
17. Do you feel that you can carry on
normal daily tasks? Do you procrastinate? ____
18. Do you have patience when working
with others?____
19. Do you have confidence in your
abilities? Do you hold back from attempting to do things for fear of
failure?____
20. Do you have fears or phobias (for
example: fear of heights, the dark, public
speaking water, being
alone, etc...)?____
21. Do you feel overshadowed by gloom or
despair for no apparent reason?____
22. Are you a fighter that never gives up
despite hardships?____
23. Do you feel mentally and physically
exhausted?____
24. Do you blame yourself for everything
that goes wrong? Do you harbor feelings of guilt?____
25. Do you worry excessively about loved
ones?____
26. Do you feel frightened or terrified?
Do you have feelings of shock or hysteria?____
27. Are you excessively hard on yourself?
Do you deny yourself life's pleasures?____
28. Are you indecisive? Do your moods
change drastically or do you feel out of balance?____
29. Do you feel tremendous grief or
trauma? Do you refuse to allow others to console you?____
30. Do you feel that you have reached
your limit of mental anguish or despair?____
31. Do you feel the need to convince
others of you beliefs and ideas? Are you over-bearing in doing
so?____
32. Are you domineering? Do you expect
others to do things your way?____
33. Are you in a time of transition, in a
situation where you have to adapt to new beginnings. Do you find
yourself under peer pressure or the influence of
others?____
34. Are you a loner? Do you find it
difficult to form close relationships with others?____
35. Do you experience sleepless nights,
where thoughts race over and over in you mind?____
36. Do you feel dissatisfied and
uncertain of your direction in life, but feel strongly that you need
to accomplish something important?____
37. Do you feel that you are stuck in a
rut, with no way to improve your situation?____
38. Do you feel that life has been unfair
to you, causing resentment and bitterness?____
COMMENTS:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
We carry all 38 Bach Flower Remedies
and can provide the correct combination
needed for each individual
Single remedies are also available,
see product page for pricing
Send this form along with a
check or money order for $16.95
plus shipping and handling
for a 2 ounce dropper bottle to:
DISCOVERING
WELLNESS
521 N. Longwood
Street
Rockford, IL
61107
Dose for all Bach Flower Remedies:
4 drops under tongue 4 x a day
Rescue Remedy is taken as needed
A 2 oz. bottle will last approximately
5 weeks when taken as directed
NOTE* Please let us know if you are alcohol
sensitive, as remedies can be purchased
with an alcohol or non-alcohol preservative
If you
have any questions or need further information
please e-mail us
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