Flower Essence Questionnaire

Instructions to determine the Flower Essence or blend for you:

  1. You may want to print this page
  2. Please take a quiet moment to read through the following statements.
  3. Take note of/tick any statements that apply to your present situation.
  4. You may tick 0, 1, 2 or all 3 statements under a flower name, this is all ok.
  5. There are no good or bad answers, just tick what honestly resonates with you.
  6. Then decide on the (1- 5) flowers that are most indicated for you (those with the most ticks).

If you need more help to decide, you can find detailed description of the indication for each flower essence on the Bach Flower website to compare your choice with.

Order instructions at the bottom.

Agrimony
[ ] I hide my feelings behind a facade of cheerfulness
[ ] I dislike arguments and often give in to avoid conflict
[ ] I turn to food, work, alcohol, drugs, etc. when down

Aspen
[ ] I feel anxious without knowing why
[ ] I have a secret fear that something bad will happen
[ ] I wake up feeling anxious

Beech
[ ] I get annoyed by the habits of others
[ ] I focus on others’ mistakes
[ ] I am critical and intolerant

Centaury
[ ] I often neglect my own needs to please
[ ] I find it difficult to say “no”
[ ] I tend to be easily influenced

Cerato
[ ] I constantly second-guess myself
[ ] I seek advice, mistrusting my own intuition
[ ] I often change my mind out of confusion

Cherry Plum
[ ] I’m afraid I might lose control of myself
[ ] I have sudden fits of rage
[ ] I feel like I’m going crazy

Chestnut Bud
[ ] I make the same mistakes over and over
[ ] I don’t learn from my experience
[ ] I keep repeating the same patterns

Chicory
[ ] I need to be needed and want my loved ones close
[ ] I feel unloved and unappreciated by my family
[ ] I easily feel slighted and hurt

Clematis
[ ] I often feel spacey and absent minded
[ ] I find myself unable to concentrate for long
[ ] I get drowsy and sleep more than necessary

Crab Apple
[ ] I am overly concerned with cleanliness
[ ] I feel unclean or physically unattractive
[ ] I tend to obsess over little things

Elm
[ ] I feel overwhelmed by my responsibilities
[ ] I don’t cope well under pressure
[ ] I have temporarily lost my self-confidence

Gentian
[ ] I become discouraged with small setbacks
[ ] I am easily disheartened when faced with difficulties
[ ] I am often skeptical and pessimistic

Gorse
[ ] I feel hopeless, and can’t see a way out
[ ] I lack faith that things could get better in my life
[ ] I feel sullen and depressed

Heather
[ ] I am obsessed with my own troubles
[ ] I dislike being alone and I like to talk
[ ] I usually bring conversations back to myself

Holly
[ ] I am suspicious of others
[ ] I feel discontented and unhappy
[ ] I am full of jealousy, mistrust, or hate

Honeysuckle
[ ] I’m often homesick for the “way it was”
[ ] I think more about the past than the present
[ ] I often think about what might have been

Hornbeam
[ ] I often feel too tired to face the day ahead
[ ] I feel mentally exhausted
[ ] I tend to put things off

Impatiens
[ ] I find it hard to wait for things
[ ] I am impatient and irritable
[ ] I prefer to work alone

Larch
[ ] I lack self-confidence
[ ] I feel inferior and often become discouraged
[ ] I never expect anything but failure

Mimulus
[ ] I am afraid of things such as spiders, illness, etc.
[ ] I am shy, overly sensitive, and modest
[ ] I get nervous and embarrassed

Mustard
[ ] I get depressed without any reason
[ ] I feel my moods swinging back and forth
[ ] I get gloomy feelings that come and go

Oak
[ ] I tend to overwork and keep on in spite of exhaustion
[ ] I have a strong sense of duty and never give up
[ ] I neglect my own needs in order to complete a task

Olive
[ ] I feel completely exhausted, physically and/or mentally
[ ] I am totally drained of all energy with no reserves left
[ ] I have just been through a long period of illness or stress

Pine
[ ] I feel unworthy and inferior
[ ] I often feel guilty
[ ] I blame myself for everything that goes wrong

Red Chestnut
[ ] I am overly concerned and worried about my loved ones
[ ] I am distressed and disturbed by other people’s problems
[ ] I worry that harm may come to those I love

Rock Rose
[ ] I sometimes feel terror and panic
[ ] I become helpless and frozen when afraid
[ ] I suffer from nightmares

Rock Water
[ ] I set high standards for myself
[ ] I am strict with my health, work &/or spiritual discipline
[ ] I am very self-disciplined, always striving for perfection

Scleranthus
[ ] I find it difficult to make decisions
[ ] I often change my opinions
[ ] I have intense mood swings

Star of Bethlehem
[ ] I feel devastated due to a recent shock
[ ] I am withdrawn due to traumatic events in my life
[ ] I have never recovered from loss or fright

Sweet Chestnut
[ ] I feel extreme mental or emotional heartache
[ ] I have reached the limits of my endurance
[ ] I am in complete despair, all hope gone

Vervain
[ ] I get high-strung and very intense
[ ] I try to convince others of my way of thinking
[ ] I am sensitive to injustice, almost fanatical

Vine
[ ] I tend to take charge of projects, situations, etc.
[ ] I consider myself a natural leader
[ ] I am strong-willed, ambitious and often bossy

Walnut
[ ] I am experiencing change in my life–a move, new job, etc.
[ ] I get drained by people or situations
[ ] I want to be free to follow my own ambitions

Water Violet
[ ] I give the impression that I’m aloof
[ ] I prefer to be alone when overwhelmed
[ ] I often don’t connect with people

White Chestnut
[ ] I am constantly thinking unwanted thoughts
[ ] I relive unhappy events/ arguments over and over again
[ ] I am unable to sleep at times because I can’t stop thinking

Wild Oat
[ ] I can’t find my path in life
[ ] I am drifting in life and lack direction
[ ] I am ambitious but don’t know what to do

Wild Rose
[ ] I am apathetic and resigned to whatever happens
[ ] I have the attitude, “It doesn’t matter anyhow”
[ ] I feel no joy in life

Willow
[ ] I feel resentful and bitter
[ ] I have difficulty forgiving and forgetting
[ ] I think life is unfair and have a “Poor me attitude”

********************************************
The (up to 5) most indicated/ highest scoring flower essences for my personal situation are;
1. ………………………………………………..
2. ………………………………………………..
3. ………………………………………………..
4. ………………………………………………..
5. ………………………………………………..

To order and arrange pick up, please contact:
Esther Ritmeester
Esther’s Homeopathy Clinic, Tokoroa
0276192781
homeopractice@hotmail.co.nz

(1x 30ml bottle of Flower essence @$15)


Please feel free to share your thoughts here!