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The Symptoms

Do you suffer from any of these symptoms?

Others: ______________________________________________________________________________

Do you have or feel one or more of the following Negative Emotional Issues?  (Please circle those that apply to you)

Burdens & Responsibilities: carrying a heavy load, the weight of the world on your shoulders.
Self Expression Issues: lack of trust, inability to speak feelings, lack of nurturing.
Grief, Sorrow, Sadness, Loss: emptiness of heart, lack of love, helplessness, loneliness, disillusionment, embarrassment, shame, humiliation, repressed feelings, disappointment, genetic or ancient memory, cruelty, meanness.
Fears & Phobias: loss of control, fear of losing control, giving up power to another person, relationships.
Anger & Rage: anger at others, anger at self, jealousy, and resentment.
Guilt/Shame/Unworthiness: Un acceptance, self-judgment, and self-criticism, not deserving of what the good life has for us, inability to accept and receive.
Family & Sexual Issues: childhood conditioning, violation of body or personal space, something done to us/something taken from us with our permission, molestation, abuse, rape, impotence, frigidity.
Survival: feeling we won’t survive a life threatening incident: violations related to surviving (accidents, abuse, violence, rape), impotence, frigidity, first year of life, basic creativity.
Betrayal: betrayed by someone you trust, self-betrayal, you betrayed someone else.
Support: lack of emotional support, lack of financial support.
Rejection: abandonment, criticism and judgment by others, self-rejection, pain in the heart.

Circle any of the following that apply to you personally or to someone in relation to you since your childhood up to now!

Abandonment, Anger, Anxiety, Apathy, Betrayal, Bothersome, Carelessness, Cluttering, Concern, Confusion, Contradiction, Criticism, Daisy, Decision Making, Depression, Deprivation, Despair, Disagree, Disappointment, Discouragement, Disgrace, Discomfort, Disgust, Dishonor, Dishonest, Dislike, Disillusionment, Distrust, Dissatisfaction, Dominating, Embarrassment, Envy, Exhibitionism, Failure, Faithless, Fear, Frustration, Geopathic Stress, Grief, Guilt, Hatred, Helplessness, Hopelessness, Ignoring, Impatience, Inability, Inadequacy, Inefficiency, Inferiority Complex, Insecurity, Interest, Irritate, Intimacy, Non-Sexual Intimacy, Sexual Irritability, Jealousy, Joy, Loneliness, Love, Low Self Esteem, Low Self Worth, Mean, Misfortune, Money, Obstinate, Overconfidence, Overprotective, Over Thinking, Panic, Passion, Peace, Pensiveness, Phobia, Poor Concentration, Procrastination, Quarrelsome, Rage, Rejection, Resentment, Restlessness, Sadness, Selfishness, Shame, Spirituality, Stubborn, Suffocation, Stress, Superiority Complex, Terror, Undeserving, Worry.