Name *

First Name

Last Name

Agrimony - Agrimonia eupatoria *

Does it seem that you are wearing a social mask, appearing carefree and cheerful to others, when deep inside you feel quite tormented?

Always

Sometimes

Never

Agrimony - Agrimonia eupatoria *

Were you taught to deny your real feelings, to keep a “stiff upper lip,” or maintain a veneer of social politeness?

Always

Sometimes

Never

Agrimony - Agrimonia eupatoria *

Do you often rely on alcohol or other drugs to keep back any unpleas- ant or troubling emotions, or to help you to feel at ease?

Always

Sometimes

Never

Aloe Vera - Aloe vera *

Do you tend to neglect basic emotional or physical needs in order to accomplish goals or projects?

Always

Sometimes

Never

Aloe Vera - Aloe vera *

Are you currently in a state of “burn-out” due to a physical, emotional, or otherwise challenging situation?

Always

Sometimes

Never

Aloe Vera - Aloe vera *

Would you characterize yourself as a typically “fiery” person with a great deal of enthusiasm and personal ambition?

Always

Sometimes

Never

Alpine Lily - Lilium parvum *

Is it hard for you to relate to the feminine aspect in yourself or others in an earthy or physical way?

Always

Sometimes

Never

Alpine Lily - Lilium parvum *

For men: Do you tend to put women “on a pedestal,” or think of them as being more spiritual than physical?

Always

Sometimes

Never

Not Applicable

Alpine Lily - Lilium parvum *

For women: Are you currently experiencing congestion or other dis- turbances in your reproductive system?

Always

Sometimes

Never

Not Applicable

Alpine Lily - Lilium parvum *

For women: Is it hard for you to have a positive experience of basic female biological functions such as menstruation, pregnancy, nursing or sexuality?

Always

Sometimes

Never

Not Applicable

Angel’s Trumpet - Datura candida *

Are you going through an intense inner experience, which feels as though some part of you is dying or encountering very deep change?

Always

Sometimes

Never

Angel’s Trumpet - Datura candida *

Do you have a terminal illness which fills you with great fear, because it’s hard to think about dying?

Always

Sometimes

Never

Angel’s Trumpet - Datura candida *

Do you have a terminal illness which fills you with great fear, because it’s hard to think about dying?

Always

Sometimes

Never

Angel’s Trumpet - Datura candida *

Is it difficult for you to surrender or to submit yourself to any process which requires spiritual faith or trust?

Always

Sometimes

Never

Angelica - Angelica archangelica *

Do you tend to see others, and the world in general, in purely physical or material terms?

Always

Sometimes

Never

Angelica - Angelica archangelica *

Are you going through an experience which requires spiritual protection and guidance?

Always

Sometimes

Never

Angelica - Angelica archangelica *

Do you often feel a deep sense of loneliness, as though you are isolated or separated from a spiritual source?

Always

Sometimes

Never

Arnica - Arnica mollis *

Have you suffered a major trauma such as an accident or surgery from which you feel you never fully recovered?

Always

Sometimes

Never

Arnica - Arnica mollis *

Are you currently experiencing shock or numbness due to trauma of any kind?

Always

Sometimes

Never

Arnica - Arnica mollis *

Do you feel that you do not fully inhabit some part of your body, or that it is generally difficult for your body to heal from wounds or other injuries?

Always

Sometimes

Never

Aspen - Populus tremula *

Do you often find yourself anxious or fearful, or experience vaguely troubling nightmares, yet are at a loss to understand what is causing or prompting these feelings?

Always

Sometimes

Never

Aspen - Populus tremula *

Do you need to bring more spiritual strength and confidence to your daily life, transforming fear and anxiety to more wakeful perception and inner knowing?

Always

Sometimes

Never

Baby Blue Eyes - Nemophila menziesii *

Is it hard for you to let down your guard around others, or to trust they can help you?

Always

Sometimes

Never

Baby Blue Eyes - Nemophila menziesii *

Did your early childhood experience include abandonment by your father, or the absence of a loving and supportive father?

Always

Sometimes

Never

Baby Blue Eyes - Nemophila menziesii *

Do you often have a rather cynical or skeptical attitude toward life, or feel that you must “go it alone”?

Always

Sometimes

Never

Basil - Ocimum basilicum *

Do your values regarding sexuality and spirituality feel in conflict with one another, as though both cannot really exist at the same time?

Always

Sometimes

Never

Basil - Ocimum basilicum *

Does your sexuality have a clandestine or secretive aspect to it, such as a hidden love affair?

Always

Sometimes

Never

Basil - Ocimum basilicum *

Do you participate in shame-based sexual conduct, or in sexual activi- ties which seem demeaning or dehumanizing?

Always

Sometimes

Never

Beech - Fagus sylvatica *

Do you set high standards for others, making it almost impossible for them to live up to your ideals?

Always

Sometimes

Never

Beech - Fagus sylvatica *

Does it seem that you are frequently in a position of criticizing or judg- ing the behavior or performance of others?

Always

Sometimes

Never

Beech - Fagus sylvatica *

Are you hypersensitive to the physical and social environment around you, needing to be surrounded by a “bubble” of perfection?

Always

Sometimes

Never

Black Cohosh - Cimicifuga racemosa *

In looking at your family history do you see a pattern of violence or abuse?

Always

Sometimes

Never

Black Cohosh - Cimicifuga racemosa *

Are you currently involved in an exploitative or violent relationship?

Always

Sometimes

Never

Black Cohosh - Cimicifuga racemosa *

Do you radiate intense magnetic or charismatic power, which often attracts many challenging people or situations to you?

Always

Sometimes

Never

Black-Eyed Susan - Rudbeckia hirta *

Do you often find yourself in patterns of denial, blocking things from your memory or disassociating from behavior that you do not really want to face?

Always

Sometimes

Never

Black-Eyed Susan - Rudbeckia hirta *

Do you suspect a deeply traumatic event from childhood, for which you have “emotional amnesia”?

Always

Sometimes

Never

Black-Eyed Susan - Rudbeckia hirta *

Is there a shadow side to your personality, or unrecognized part of yourself which needs more honest attention and understanding?

Always

Sometimes

Never

Blackberry - Rubus ursinus *

Do you have many plans or intentions which never seem to materialize?

Always

Sometimes

Never

Blackberry - Rubus ursinus *

Do you tend to be philosophically oriented, someone more likely to think or reflect than to organize and execute?

Always

Sometimes

Never

Blackberry - Rubus ursinus *

Do you feel sluggish, as though your physical body is lacking in essen- tial vitality or willpower?

Always

Sometimes

Never

Bleeding Heart - Dicentra formosa *

Do you feel devastated or broken-hearted by a relationship which has ended?

Always

Sometimes

Never

Bleeding Heart - Dicentra formosa *

Has a family member or friend recently died, resulting in intense feelings of grief and loneliness?

Always

Sometimes

Never

Bleeding Heart - Dicentra formosa *

Do you often find yourself in troubled relationships, especially ones in which you feel rejected?

Always

Sometimes

Never

Borage - Borago officinalis *

Do you often feel emotionally weighed down, burdened by feelings which seem oppressive or stifling?

Always

Sometimes

Never

Borage - Borago officinalis *

Are you currently experiencing a great deal of sadness, grief, or loss?

Always

Sometimes

Never

Borage - Borago officinalis *

Do you feel closed down in your heart, an almost physical sensation of weight or “heavy-heartedness” which prevents you from fully experiencing joy?

Always

Sometimes

Never

Buttercup - Ranunculus occidentalis *

Do you often find yourself apologizing for what you do or who you are?

Always

Sometimes

Never

Buttercup - Ranunculus occidentalis *

Do you feel that others are more worthy of attention or respect than you?

Always

Sometimes

Never

Buttercup - Ranunculus occidentalis *

Do you evaluate your social status by conventional standards of achievement, rather than an inner sense of your own self-worth?

Always

Sometimes

Never

Calendula - Calendula officinalis *

Do you find yourself frequently interrupting others or becoming argumentative?

Always

Sometimes

Never

Calendula - Calendula officinalis *

Is it hard for you to listen or to take genuine interest in what others are saying?

Always

Sometimes

Never

Calendula - Calendula officinalis *

Do you feel you need to develop more warmth and compassion in the way you relate to others?

Always

Sometimes

Never

Calendula - Calendula officinalis *

Do you feel you need to develop more warmth and compassion in the way you relate to others?

Always

Sometimes

Never