Adult Bach Remedy Questionnarie


Natural Treasure Holistic medicine
Mohamed El Siddig , NSHS, DMHS ( HD)
Homeopathic Doctor & Healer
Hypnopath/ Psychopath
Hamilton ,ON
Barton East
2892441179

Homeopathic consultation is facilitated when there is a complete picture of the individual’s mental, emotional and physical states of health.  This includes symptoms that affect both physical sensations (what does it feel like), and function (how it impacts you) and what ameliorates or aggravates each symptom.

Date

Your Name (required)

Age

Birthday

Sex

Address

City

Province

Postal Code

Phone (home)

Phone (work)

Phone (Cell)

Email

Occupation

Full-time/Part-time

Retired

Employed by

Education

Marriage Status

Gloom descends on you with no apparent cause.
 1 2 3 4 5 6 7 8 9

You experience regular periods of depression.
 1 2 3 4 5 6 7 8 9

You are easily offended.
 1 2 3 4 5 6 7 8 9

You feel unloved and have an inordinate need for attention.
 1 2 3 4 5 6 7 8 9

You feel unloved and have an inordinate need for attention.
 1 2 3 4 5 6 7 8 9

You recently went through a painful parting / breakup.
 1 2 3 4 5 6 7 8 9

You invest effort, but get nothing in return.
 1 2 3 4 5 6 7 8 9

You're skilled and quick on the uptake, and others find it difficult to keep up with your pace.
 1 2 3 4 5 6 7 8 9

You're high-strung and impatient.
 1 2 3 4 5 6 7 8 9

You engage in risky activities such as karting and rappelling.
 1 2 3 4 5 6 7 8 9

You hide your feelings, showing everyone that everything's OK.
 1 2 3 4 5 6 7 8 9

You use drugs or alcohol in order to calm your anxieties.
 1 2 3 4 5 6 7 8 9

You dislike being alone, and prefer to be in others company.
 1 2 3 4 5 6 7 8 9

You feel anxious in certain places or circumstances.
 1 2 3 4 5 6 7 8 9

You're bashful and afraid to speak up in a group.
 1 2 3 4 5 6 7 8 9

You live with constant regret over things that you've done, and feel that you should have to pay for your transgressions.
 1 2 3 4 5 6 7 8 9

You often feel guilty.
 1 2 3 4 5 6 7 8 9

You find yourself dealing repeatedly with the same problem; you make the same mistake repeatedly and fail to learn from experience.
 1 2 3 4 5 6 7 8 9

You have problems with your memory.
 1 2 3 4 5 6 7 8 9

You're afraid of failure, and feel that others are more successful than you.
 1 2 3 4 5 6 7 8 9

You feel that you don't perform your job well.
 1 2 3 4 5 6 7 8 9

You've gone through a tough period, and you're now sapped of energy and feel weak and drained.
 1 2 3 4 5 6 7 8 9

You're going through a stressful period and feel like you're at the end of your rope.
 1 2 3 4 5 6 7 8 9

You're often depressed.
 1 2 3 4 5 6 7 8 9

You're a pessimistic type and a negative thinker.
 1 2 3 4 5 6 7 8 9

You awaken at night from nightmares.
 1 2 3 4 5 6 7 8 9

You feel unexplained anxiety.
 1 2 3 4 5 6 7 8 9

The future looks hazy and threatening.
 1 2 3 4 5 6 7 8 9

Your preoccupation with the past and with memories interferes with your ability to function.
 1 2 3 4 5 6 7 8 9

You're nostalgic for and miss a certain period of your life.
 1 2 3 4 5 6 7 8 9

You often have a sense of being dirty and of self-disgust.
 1 2 3 4 5 6 7 8 9

You're a perfectionist.
 1 2 3 4 5 6 7 8 9

You often cannot stand yourself.
 1 2 3 4 5 6 7 8 9

You feel mentally fatigued.
 1 2 3 4 5 6 7 8 9

You find it difficult to get up in the morning and start your day.
 1 2 3 4 5 6 7 8 9

You're afraid you're going crazy.
 1 2 3 4 5 6 7 8 9

You're afraid of losing control.
 1 2 3 4 5 6 7 8 9

You find interpersonal relations difficult.
 1 2 3 4 5 6 7 8 9

You get upset when things don't go your way.
 1 2 3 4 5 6 7 8 9

You're critical and notice every detail.
 1 2 3 4 5 6 7 8 9

You're in a difficult situation from which there seems to be no way out.
 1 2 3 4 5 6 7 8 9

There is someone that you dislike or of whom you are jealous, and you wish him or her ill.
 1 2 3 4 5 6 7 8 9

You're angry.
 1 2 3 4 5 6 7 8 9

You lack love in your life, and are full of negative emotions.
 1 2 3 4 5 6 7 8 9

You're worried and preoccupied by bothersome thoughts; you have a hard time falling asleep.
 1 2 3 4 5 6 7 8 9

Stress paralyzes you to the point where you have difficulty functioning.
 1 2 3 4 5 6 7 8 9

You get stressed out or panicky in certain situations.
 1 2 3 4 5 6 7 8 9

You find it difficult to concentrate, and are uninterested in what is going on around you.
 1 2 3 4 5 6 7 8 9

You like to escape to an imaginary, fantasy world.
 1 2 3 4 5 6 7 8 9

You feel sleepy and fatigued.
 1 2 3 4 5 6 7 8 9

You demand that your children check in with you constantly.
 1 2 3 4 5 6 7 8 9

You worry constantly about your loved ones.
 1 2 3 4 5 6 7 8 9

You're despairing and without hope, and believe that there's no way out.
 1 2 3 4 5 6 7 8 9

You find yourself behaving in a subservient manner to your superiors.
 1 2 3 4 5 6 7 8 9

You give to others without limit, and you feel exploited.
 1 2 3 4 5 6 7 8 9

You lack motivation and decisiveness.
 1 2 3 4 5 6 7 8 9

You're exhausted and fatigued, and you carry the weight of the world on your shoulders.
 1 2 3 4 5 6 7 8 9

You habitually take responsibility for others, because you don't really trust them.
 1 2 3 4 5 6 7 8 9

You suffer from various problems and feel that those around you aren't interested and do not support you.
 1 2 3 4 5 6 7 8 9

You're anxious about your health; illness and death frighten you.
 1 2 3 4 5 6 7 8 9

You insist that others meet your high standards.
 1 2 3 4 5 6 7 8 9

You suffer from painful joints.
 1 2 3 4 5 6 7 8 9

You stubbornly hold to your opinions, are self-righteous, and adhere to your values.
 1 2 3 4 5 6 7 8 9

You're confused in the face of all of your options.
 1 2 3 4 5 6 7 8 9

You're at a crossroads and are searching for a direction and a goal in life.
 1 2 3 4 5 6 7 8 9

You find it difficult to make decisions independently; others' opinions take precedence over your own.
 1 2 3 4 5 6 7 8 9

You're confused and have difficulty concentrating.
 1 2 3 4 5 6 7 8 9

Others think that you're conceited or a snob.
 1 2 3 4 5 6 7 8 9

You prefer being alone, and avoid crowds.
 1 2 3 4 5 6 7 8 9

You feel disquiet, and work around the clock.
 1 2 3 4 5 6 7 8 9

You're enthused and want to persuade others of your ideas.
 1 2 3 4 5 6 7 8 9

You feel that others don't help you and that you must handle hardship alone.
 1 2 3 4 5 6 7 8 9

You feel you have bad luck.
 1 2 3 4 5 6 7 8 9

You feel disappointed by life.
 1 2 3 4 5 6 7 8 9

You experience mood swings.
 1 2 3 4 5 6 7 8 9

You feel dizzy, or as if you're losing your balance.
 1 2 3 4 5 6 7 8 9

You vacillate and find it difficult to decide between two options.
 1 2 3 4 5 6 7 8 9

Your opinion is correct and final, and you have a need to be right.
 1 2 3 4 5 6 7 8 9

You're a dominant type; it's important for you to lead and be in control.
 1 2 3 4 5 6 7 8 9

You believe that this is your fate and that you cannot change it.
 1 2 3 4 5 6 7 8 9

You suffer from an emotional void; you're apathetic toward life and what happens to you.
 1 2 3 4 5 6 7 8 9

You have experienced a great disappointment or loss.
 1 2 3 4 5 6 7 8 9

You've experienced a trauma that has left a mark on your life.
 1 2 3 4 5 6 7 8 9

You're in a transition (moving to a new home, going through puberty or menopause, have a new workplace, are going through a divorce)
 1 2 3 4 5 6 7 8 9

You're sensitive and affected by events and people around you.
 1 2 3 4 5 6 7 8 9

Homeopathy is considered to be an alternative/preventative system of health care and is not intended to be a substitute for allopathic or traditional medicine.

The therapy and information offered should not be construed by you, the client, or any family, friends or caregivers to be a medical diagnosis of any disease or injury.

You should consult with your physician for any serious medical condition and further, you should get at least two medical opinions for such condition.

While Mohamed El Siddig ,DHMS , DMLS , ( HD) ,CMA member has had extensive training in the science and art of Homeopathy .

I HAVE READ THE ABOVE AND AGREE TO ALL TERMS:

Signature

Do you agree?