| This form is designed to
provide a self-evaluation of each cycle of flower
essences use. Please use it to report your experiences
with the essences. |
| Name Date (mm/dd/yy) |
| Email
|
| Time period essences were
used (beginning) to (ending) |
| Practitioners Name
Session # |
| 1. Please list the
essences(s) in this dosage cycle and how often you
actually took them. |
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| 2. Please describe the
preexisting conditions that you were taking the essences
for. |
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| 3. Please describe any
significant changes in the conditions mentioned above
which you feel might be a result of taking the essences,
regardless of whether the change is perceived to be
positive or negative. Please mention any noticeable
changes in previous symptoms, emotional and mental
state, and general health. |
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| 4. Note any preexisting
conditions that did not seem to change during this
dosage cycle. |
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| 5. Please list any other
therapies, both traditional and alternative, that you
were involved with during this essences dosage cycle.
Please comment on whether you found them to be helpful,
and if so, in what ways. |
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| 6. How did you experience
the effects of these essences? |
|
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| 7. Based on your current
perceptions, how do you feel that this cycle of essences
was beneficial? |
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| 8. What are your
intentions and goals for your next consultation? |
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All information submitted
will be used solely for research purposes and will be
handled with strict confidentiality. |
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