Please enable JavaScript in your browser to complete this form. - Step 1 of 5The Healthy Alternative Bach Flower Questionnaire Name *DateAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthPhoneEmail *Please answer the questions on this form as they relate to the person being evaluated. Although your history and symptoms are very important in our analysis of your condition, it is also important for us that you understand: • This program is not a treatment for allergies, nor does it diagnose or relieve them. • Symptoms are your body's way of signaling stress. • We identify potential stressors and use integrative techniques such as Low-Level Light Therapy, Acupoint Stimulation, Homeopathy, Nutrition, and Energetic Information to help restore balance. • No drugs are used in this program. • Results may vary, but our approach aims to boost energy, enhance immunity, and reduce stressors for improved quality of life. • Even “healthy” substances may not be suitable for everyone. • Your diet and environment include everything you consume, apply, or inhale. • Our methods are safe, non-invasive, and painless. • For anaphylaxis, consult your primary care physician for appropriate medical treatment. The Healthy Alternative | 517-403-7408 | www.healthyalternative.website NextThe Healthy Alternative Bach Flower Questionnaire AgrimonyAre you distressed by arguments and quarrels, often "giving in" to avoid any conflict?Do you find yourself hiding your worries behind a cheerful, smiling face in an attempt to conceal your pain from others?When you feel life’s pressures weighing you down, do you often turn to alcohol or to drugs or other outside influences to help you cope?AspenDo you awaken with a sense of fear and anxiety of what the day will bring?Do you have feelings of apprehension, anticipation, or uneasiness with no known causes?Do you worry that something bad may happen but you are not sure what?BeechAre you annoyed by the habits and shortcomings of others?Do you find yourself being overly critical and intolerant, usually looking for what someone has done wrong?Do you prefer to work or be alone because the seeming foolishness of others irritates you?CentauryAre you unable to say no to those who constantly impose upon your good nature?Do you often deny your own needs in order to please others?Do you tend to be timid and shy, easily influenced by those stronger nature than yourself?CeratoAre you often seeking advice and confirmation from other people, mistrusting your own wisdom?Do you change direction often, first going one way, then another because you lack the confidence in yourself to stick with one direction?Do you constantly question your own decisions and judgment?Cherry PlumAre you afraid of hurting yourself or others?Do you fear losing control of yourself?Do you have tendency to act irrationally and violently, exploding into unexplained fits of rage and anger?Chestnut BudDo you fail to learn from your experiences?Do you find yourself making the same mistakes over and over again such as choosing the wrong type of partner or staying in a job you dislike?Does it take you longer to advance in your life because you are slow to learn from past mistakes?ChicoryAre you possessive and manipulative of those you care for?Do you need to be needed?Do you often feel unloved and unappreciated by the loved ones "after all you have done for them"?ClematisAre you drowsy and listless, sleeping more often than necessary?you find yourself preoccupied and dreamy, unable to concentrate for any length of time?Do you often feel spaced and out of touch with the "real world"?The Healthy Alternative | 517-403-7408 | www.healthyalternative.website NextThe Healthy Alternative Bach Flower Questionnaire Crab AppleAre you embarrassed and ashamed of yourself physically, finding yourself unattractive?Are you obsessed with cleanliness?Do you tend to concentrate on small conditions such as pimples or marks, neglecting more serious problems?ElmAre you often overwhelmed by your responsibilities?Do you become depressed and exhausted when faced with your everyday commitments?Do you feel inadequate when it comes to dealing with the tasks ahead of you?GentianAre you easily disheartened when faced with difficult situations?Do you become discouraged and depressed when things go wrong?Does your pessimism prevent you from making an effort to accomplish something?GorseDo you believe that nothing can be done to relieve your pain and suffering?Do you feel despondent and hopeless, at the end of your rope both mentally and physically?Do you lack confidence that things will get better in your life and therefore make no effort to improve your circumstances?HeatherAre you totally self-absorbed, concerned only about yourself and your problems and ailments?Do you dislike being alone, always seeking the companionship of others?Do you talk incessantly, not interested in what anyone else has to say?HollyAre you full of jealousy, envy, or hate?Do you feel generalized anger toward other people?Do you mistrust others’ intentions, feeling that people have "ulterior motives"?HoneysuckleAre you dissatisfied with your accomplishments?Are you unable to change present circumstances because you are always looking back and never forward?Do you find yourself living in the past, nostalgic and homesick for the "way it was"?HornbeamDo you feel overworked or bored with your life?Do you lack enthusiasm and therefore tend to procrastinate?Do you often feel too tired to face the day ahead?ImpatiensAre you impatient and irritable with others who seem to do things too slowly for you?Do you feel a sense of urgency in everything you do, always rushing to get through things?Do you prefer to work alone?MimulusAre you shy, overly sensitive, and often afraid?Do you have fears of known things, such as illness, death, pain, heights, darkness, snakes, etc.?When you are confronted with a frightening situation, do you become too paralyzed to act?The Healthy Alternative | 517-403-7408 | www.healthyalternative.website NextThe Healthy Alternative Bach Flower Questionnaire MustardDo you feel deep gloom that seems to quickly descend for no apparent reason and lifts just as suddenly?Do you feel depressed without knowing why?Do you feel your moods swinging back and forth?OakAre you exhausted but feel the need to struggle on against all odds?Do you have a strong sense of duty and dependability, carrying on no matter what obstacles stand in your way?Do you neglect your own needs to complete a task?OliveAre you totally drained of all energy with no reserves left to carry on?Do you feel utterly and completely exhausted, both physically and mentally?Is everything an effort, does your life lack zest?PineAre you full of guilt and self-reproach?Do you blame yourself for everything that goes wrong, including the mistakes of others?Do you set overly high standards for yourself, never satisfied with your achievements?Red ChestnutAre you distressed and disturbed by other people’s problems?Are you excessively concerned and worried for your loved ones?Do you constantly worry that harm may come to loved ones, family members, or others you care for?Rock RoseDo you become helpless and frozen in the face of your fear?Do you feel terror and panic?Do you suffer from nightmares?Rock WaterAre you inflexible in your approach to life, always striving for perfection?Are you overly concerned with diet, exercise, work, and spiritual disciplines?Are you so rigid in your ideals that you deny yourself the simple pleasures of life?ScleranthusDo you find it difficult to decide when faced with a choice of two possibilities?Do you lack concentration, always fidgety and nervous?Do your moods change from one extreme to another: joy to sadness, optimism to pessimism, laughing to crying?Star of BethlehemAre you numbed or withdrawn as a result of recent traumatic events in your life?Have you suffered a loss or grief that you have never recovered from?Have you suffered a shock in your life such as an accident, loss of a loved one, terrible news, illness?Sweet ChestnutDo you feel as though the future holds nothing for you?Do you feel that you have reached the limits of what you could possible endure?Do you suffer from extreme mental anguish?The Healthy Alternative | 517-403-7408 | www.healthyalternative.website Oat Mustard Layout NextThe Healthy Alternative Bach Flower Questionnaire VervainDo you feel tense and highly strung?Do you have strong opinions and only yours are the right ones?Is your over-enthusiasm almost to the point of being fanatical?VineAre you inflexible and feel you know more than anyone else?Do you feel the need to always to be right?Do you tend to be domineering and overbearing?WalnutAre you distracted by outside influences?Are you experiencing any change in your life–a move, new job, loss of a loved one, new relationship, divorce, puberty, menopause, or giving up an addiction?Do you need to make a break from strong forces or attachments in your life that may be holding you back?Water VioletDo you appear to others to be aloof and overly proud?Do you bear your grief and sorrow in silence?Do you have tendency to be withdrawn and prefer to be alone when faced with too many distractions?White ChestnutAre you unable to sleep at times because your mind seems to be cluttered with mental arguments that go round and round?Do you relive unhappy events or arguments over and over again?Do you find your head full of persistent, unwanted thoughts that prevent concentration?Wild OatAre you displeased with your lifestyle and feel dissatisfied with your achievements?Do you find yourself in a complete state of uncertainty over major life decisions?Do you have ambition but feel that life is passing you by?Wild RoseAre you apathetic and resigned to whatever may happen in your life?Do you have the attitude, "I will just live with it"?Do you lack the motivation to improve the quality of your life?WillowDo you feel life is unfair and find yourself taking less and less interest in the things you used to enjoy?Do you feel resentful and bitter?Do you have difficulty forgiving and forgetting?The Healthy Alternative | 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