Make your own free website on




The following questionnaire was developed from the original writings of Dr. Edward Bach and is provided for your interest and self-assessment. Individual remedies and multiple remedy formulas are available by telephone by contacting the Kachina Healing Center at 1-928-759-2612 or by email (click here)

Please read and answer each of the questions carefully. After completing the Questionnaire in full, refer to the answer key on the last page for further instructions.

Check only those questions for which you gave a definite YES answer. If your answer is NO or SOMETIMES, leave the box blank.


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 referred to a physician immediately.


____ 1. Do you have vague fears which you cannot explain?

____ 2. Do you often find yourself distressed and anxious, but are unable to put your finger on the problem?

____ 3. Do you wake with a sense of apprehension and foreboding, feeling that something bad may happen, but don’t know what it may be?


____ 4. Do you have specific fears you can identify and would like to overcome?

____ 5. Are you shy and easily frightened by particular circumstances and things?

____ 6. When faced with situations or things that frighten you, do you become nervous and too paralyzed to act?


____ 7. Do you fear losing control of your mind or body?

____ 8. Are you compulsive, or have impulses to do things you know are wrong, but have difficulty controlling your actions?

____ 9. Do you fear losing control and hurting yourself or others?


____ 10. Do you worry over the health and safety of your friends and family?

____ 11. Do you fear that something may happen to those close to you?

____ 12. Does your over-concern and worry for others cause you considerable distress?


____ 13. Do you suffer from extreme terror?

____ 14. Do you tend to panic and become hysterical?

____ 15. Are you troubled by nightmares?


____ 16. Do you lack confidence in your ability to judge things on your own and make decisions?

____ 17. Do you find yourself asking other people’s advice, even when you know what you want?

____ 18. After taking advice from others, do you find yourself confused by the choices, constantly changing your direction according to the latest recommendation?


____ 19. Do you suffer from indecision, uncertainty or hesitancy?

____ 20. Do you have difficulty choosing between one thing and another?

____ 21. Do you experience extreme mood swings, or have difficulty in keeping your balance?


____ 22. Are you dissatisfied with your current role in life, feeling that life is passing you by?

____ 23. Have you tried many different directions in life, but nothing seems to bring satisfaction?

____ 24. Would you like to find a new lifestyle, career or change your old one, but have difficulty deciding what you should be doing?


____ 25. Do you lack confidence?

____ 26. Do you not try things for fear of failing?

____ 27. Do you feel inferior, and that others are more capable and qualified than you?


____ 28. On rising in the morning, do you find yourself tired, not wanting to get up?

____ 29. Do you feel some part of you needs to be strengthened before you can tackle the day?

____ 30. Do you find once you have started your daily activities your tiredness is forgotten, and you’re able to complete your task?


____ 31. Are you absentminded, or does your attention easily wander, making it difficult to concentrate?

____ 32. Do you find you have little interest in present circumstances, often daydreaming, wishing you were somewhere else?

____ 33. Do you find yourself dozing off frequently, regardless of where you are?


____ 34. Do you find you are caught between living in the present and dwelling in memories of the past?

____ 35. Are there things you would like to have done with your life but never had the opportunity to do?

____ 36. Do you find yourself reminiscing about the good old days, wishing you were able to live your life over again?


____ 37. Do you find you are indifferent and apathetic toward life?

____ 38. Are you resigned to your current circumstances, making little effort to improve things or find joy?

____ 39. Do you feel you’ve given up and don’t care one way or another what happens?


____ 40. Are you troubled by persistent unwanted thoughts?

____ 41. Do you worry or have mental arguments which circle round in your mind?

____ 42. Do you have difficulty sleeping due to mental chatter and worries?


____ 43. Do you find you don’t learn from past experiences, repeating the same mistakes or patterns of behavior?

____ 44. Due to lack of observation, do you find it necessary to go over things already done?

____ 45. Is there a particular situation or condition continually recurring in your life which you would like to overcome?


____ 46. Are you now going through, or have you recently gone through, an illness or personal ordeal which left you physically and mentally drained?

____ 47. Do you tire easily with no reserve energy to complete your tasks or enjoy the day?

____ 48. Do you feel sapped of strength and vitality, where even the least effort exhausts you?


____ 49. Do others find you aloof, prideful and at times condescending?

____ 50. Do you keep to yourself, not wishing to be interfered with or to interfere in other people’s affairs?

____ 51. Are you self-reliant and prefer spending your time alone?


____ 52. Do you find yourself losing patience, becoming tense and irritable with people and things that move too slowly for you?

____ 53. Do you do things in a rush, racing from one place or situation to another?

____ 54. Do you find you need to work alone, because other’s can’t keep up your pace?


____ 55. Do you find others avoiding conversation with you because you tend to talk a great deal?

____ 56. Do you dislike being alone and seek the company of anyone willing to listen to your troubles?

____ 57. 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?


____ 58. When worried or in pain, do you tend to conceal it from others, making light of even the most trying of circumstances?

____ 59. 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 or quarrel?

____ 60. When troubled, do you find yourself drinking alcohol or using stimulants or other drugs to assist in keeping up a happy disposition?


____ 61. Are you easily imposed on because of your willingness to help others?

____ 62. Is it difficult for you to say no when you’re asked for help, becoming more a servant than a willing helper?

____ 63. Do you neglect your own needs, because you are too busy taking care of other’s people’s needs?


____ 64. Are you involved in a relationship or situation you would like to be free of, but cannot break away from?

____ 65. Are you currently in a state of transition or change?

____ 66. 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?


____ 67. Are you suspicious and mistrusting of other people’s motives and intentions?

____ 68. Do others find you spiteful, envious, jealous or vengeful?

____ 69. Do you find yourself lacking compassion or warmth toward others?


____ 70. Are you rarely content with your accomplishments, feeling that you could always do better?

____ 71. Do you blame yourself for other people’s mistakes, feeling that their shortcomings are in some way your fault or responsibility?

____ 72. Are you hard on yourself when you fail to live up to the standards or expectations you’ve set for yourself?


____ 73. Do you tend to overextend your commitments?

____ 74. Do you find yourself overwhelmed by your work, and despite being capable feel you have taken on more than you can do?

____ 75. Do you become despondent when faced with the magnitude of your responsibilities?



____ 76. Have there been past traumas or shocks in your life, which you may not have completely recovered from?

____ 77. Do you feel a past surgery or accident is responsible for your present condition?

____ 78. Have you recently, or in the past, suffered a personal loss which you haven’t quite gotten over?


____ 79. Do you feel you’ve reached the limits of your endurance, and there’s nothing but annihilation left to face?

____ 80. Do you suffer from mental anguish and deep despair?

____ 81. Do you feel that the burden of life is more than you can bear?


____ 82. Have you lost hope that you will recover from or be helped in overcoming an illness or difficulty?

____ 83. Do you feel it is useless to seek further help for your problems?

____ 84. Have you given up hope that things will change for the better in some circumstance or situation in your life?


____ 85. Do you ever become gloomy and depressed for no known reason?

____ 86. Does this depression envelope you like a dark cloud, hiding the joy of life?

____ 87. Do you find this gloom and depression, for no apparent reason, lifts as suddenly as it comes?


____ 88. Are you easily discouraged when things don’t go your way?

____ 89. 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?

____ 90. Is it hard for you to start over again once you’ve encountered difficulties?


____ 91. Are you one who tirelessly struggles on despite oppositions and delays?

____ 92. Can you always be depended on to complete what you set out to do, regardless of the challenge?

____ 93. Do you tend to throw yourself into your projects neglecting your own needs, as well as the needs of those close to you?


____ 94. Through no fault of your own, do you feel that life has been unfair or unjust to you?

____ 95. Have you become resentful and bitter toward those who may have treated you poorly?

____ 96. Despite all you have done, do you feel your bet efforts have largely gone unrewarded, while others not as deserving as yourself, have gained?


____ 97. Do you feel unclean or ashamed over an act you should not have committed, or over someone or something having violated you personally?

____ 98. Do you find yourself preoccupied with small physical problems such as pimples, small blemishes or rashes, while overlooking more serious conditions?

____ 99. Do you feel there is something wrong with, or some things you would like changed, in your physical appearance?

____ 100. Are you compulsive about cleanliness, even at times to the extreme?

____ 101. Are you afraid of becoming, or feel you have already become, contaminated and need to be cleansed?


____ 102. Are you possessive of those close to you and feel you know what’s best for them, often directing and correcting even small details of their lives?

____ 103. Do you feel you are not appreciated by those you care for?

____ 104. 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?


____ 105. When assessing people and situations, do you look for what you can find wrong?

____ 106. Do the small habits and idiosyncrasies of others bother you?

____ 107. Are you critical and intolerant of those who don’t measure up to your standards or expectations?


____ 108. Do you have strong opinions which you attempt to convince others are right?

____ 109. Are you easily incensed by injustices, arguing for and defending principles which you believe in?

____ 110. Are you high-strung, at times tense and over-enthusiastic, always teaching and philosophizing?


____ 111. Do you feel you have a mission in life to conform with or live up to?

____ 112. Are you strict in your adherence to a religious or social discipline, or in a particular way of living?

____ 113. Do you feel it’s important to make an example of yourself by living up to your ideals, so that others may follow?


____ 114. Do you tend to take charge in circumstances and situations you’re involved with?

____ 115. Are you strong-willed and expect complete obedience (without question) from those around you?

____ 116. Do you consider yourself a "born leader?"



---------------------------------------------------- ANSWER KEY -------------------------------------------------------

Count the number of checks (for Yes answers) in each of the given question groupings (example 1-3). If there are two or more Yes answers in a question group, put a check next to that Remedy.

Then refer to our catalog for a detailed description of each of the Remedies you have checked. Select by priority the Remedies you feel you need most. Remember – up to six Remedies may be combined and taken at one time. No more than six to eight.

This questionnaire is meant for your personal confidential use and should be referred to when ordering. Please keep this completed questionnaire in your possession.







1 - 3 Aspen __ 58 - 60 Agrimony __
4 - 6 Mimulus __ 61 - 63 Centaury __
7 - 9 Cherry Plum __ 64 - 66 Walnut __
10 - 12 Red Chestnut __ 67 - 69 Holly __
13 - 15 Rock Rose __ 70 - 72 Pine __
16 - 18 Cerato __ 73 - 75 Elm __
19 - 21 Scleranthus __ 76 - 78 Star of Bethlehem __
22 - 24 Wild Oat __ 79 - 81 Sweet Chestnut __
25 - 27 Larch __ 82 - 84 Gorse __
28 - 30 Hornbeam __ 85 - 87 Mustard __
31 - 33 Clematis __ 88 - 90 Gentian __
34 - 36 Honeysuckle __ 91 - 93 Oak __
37 - 39 Wild Rose __ 94 - 96 Willow __
40 - 42 White Chestnut __ 97 - 101 Crab Apple __
43 - 45 Chestnut Bud __ 102 - 104 Chicory __
46 - 48 Olive __ 105 - 107 Beech __
49 - 51 Water Violet __ 108 - 110 Vervain __
52 - 54 Impatiens __ 111 - 113 Rock Water __
55 - 57 Heather __ 114 - 116 Vine __

Kachina Healing Center, LLC
8456 E. Loos Drive
Prescott Valley, AZ 86314 U.S.A.