Chakra Assessment

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Name *

First

Last

Email *

Phone Number *

01. Do you feel uncomfortable with change? *

02. Are you constantly on the go? *

03. Do you have trouble with sleeping or staying asleep? *

04. Do you have issues with your legs, knees, or feet? *

05. Do you have a hard time being still? *

06. Do you feel stuck and unable to move forward? *

07. Do you lack creativity? *

08. Do you have lower back or hip problems? *

09. Do you feel problems sharing your emotions? *

10. Are you aware of your emotions? *

11. Do you have feminine problems? *

12. Are you overly emotional or not emotional at all? *

13. Do you lack joy in your life? *

14. Do you have guilt? *

15. Are you often tired or lack energy through the day? *

16. Do you have a sugar addiction? *

17. Are you feeling lost or confused? *

18. Do you have digestive problems? *

19. Are you lacking self-confidence or overly confident? *

20. Do you carrier around shame? *

21. Are you a perfectionist? *

22. Do you get angry easily? *

23. Do you have trust issues? *

24. Do you have problems with your arms or your heart? *

25. Are you constantly giving? *

26. Do you have a hard time accepting compliments or help? *

27. Do you have negative self-talk? *

28. Do you have relationship problems? *

29. Do you hold onto resentment? *

30. Do you have neck pain or shoulder pain? *

31. Do you say YES to others when you want to say NO? *

32. Do you communicate your feelings and desires easily? *

33. Do you get sore throats or ear infections? *

34. Are you soft spoken or do you speak really loud? *

35. Do you gossip about others? *

36. Do you run old stories over in your mind? *

37. Do you question yourself with your choices? *

38. Do you have problems with your eyes? *

39. Do you have hormonal imbalances? *

40. Can you see things from another perspective is? *

41. Do you have a poor memory? *

42. Do you feel you are intutitve? *

43. Do you feel a lack of guidance from a higher power? *

44. Do you have a lot of doubt? *

45. Do you get headaches or migraines? *

46. Is your head full of thoughts all the time? *

47. Do you have a problem with settling your mind? *

48. Do you have a hard time finding gratitude in the simple and/or more complex things in life? *

49. Do you feel like you have direction in your life? *

You will be re-directed to BKISS scheduling website upon submittal.

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Chakra Assessment

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