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Emotional Layer Questionnaire
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FIRST CHAKRA (Root Chakra)
Do you have haemorrhoids?
Do you have haemorrhoids?
Yes
No
Do you feel pain in the lower vertebrae of your spine?
Do you feel pain in the lower vertebrae of your spine?
Yes
No
Do you experience hips pain?
Do you experience hips pain?
Yes
No
Do you experience knee pain?
Do you experience knee pain?
Yes
No
Do you experience joint pain?
Yes
No
Do you feel constant pain in your leg muscles?
Yes
No
Are you scared for your family?
Yes
No
Are you fearful for your financial condition?
Yes
No
SECOND CHAKRA (Sacral Chakra)
Do you feel pain in you lower back?
Do you feel pain in you lower back?
Yes
No
Do you have painful menstrual cycles?
Do you have painful menstrual cycles?
Yes
No
Do you have negative relations with your partner?
Do you have negative relations with your partner?
Yes
No
Is your relationship with your parents negative?
Is your relationship with your parents negative?
Yes
No
Do you have cists?
Do you have cists?
Yes
No
Do you have other gynaecological problems?
Do you have other gynaecological problems?
Yes
No
Do u experience lack of creativity?
Do u experience lack of creativity?
Yes
No
THIRD CHAKRA (Solar Plexus Chakra)
Do you often feel lack of energy even though you haven’t worked hard?
Do you often feel lack of energy even though you haven’t worked hard?
Yes
No
Do you lack confidence?
Do you lack confidence?
Yes
No
Do you have problems with some of your stomach organs?
Do you have problems with some of your stomach organs?
Yes
No
Do you experience problems at work?
Do you experience problems at work?
Yes
No
Does your belly button hurt above and behind?
Does your belly button hurt above and behind?
Yes
No
FOURTH CHAKRA (Heart Chakra)
Do you have Tachycardia?
Do you have Tachycardia?
Yes
No
Do you experience sharp pains in your heart?
Do you experience sharp pains in your heart?
Yes
No
Are you feeling sad?
Are you feeling sad?
Yes
No
Are you taking deep or short breaths?
Are you taking deep or short breaths?
Deep
Short
Do u feel like you have a rock in your heart?
Do u feel like you have a rock in your heart?
Yes
No
FIFTH CHAKRA (Throat Chakra)
Do you feel like you have lump in your throat?
Do you feel like you have lump in your throat?
Yes
No
Do your teeth decay easily?
Do your teeth decay easily?
Yes
No
Does you throat irritate easily?
Does you throat irritate easily?
Yes
No
Is your thyroid ok?
Is your thyroid ok?
Yes
No
Do you resist speaking up often?
Do you resist speaking up often?
Yes
No
Do you speak with high volume?
Do you speak with high volume?
Yes
No
Do u feel pain in your upper back in between the shoulders?
Do u feel pain in your upper back in between the shoulders?
Yes
No
Do you experience shoulder pain often?
Do you experience shoulder pain often?
Yes
No
SIXTH CHAKRA (Third Eye Chakra)
Do you have problems with your eyes?
Do you have problems with your eyes?
Yes
No
Do you have problems with your ears?
Do you have problems with your ears?
Yes
No
Do you have headaches?
Do you have headaches?
Yes
No
Do you have a situation that you can’t stand, but you have to?
Do you have a situation that you can’t stand, but you have to?
Yes
No
Do you have blood pressure variations?
Do you have blood pressure variations?
Yes
No
Do you have problems with your hormones?
Do you have problems with your hormones?
Yes
No
SEVENTH CHAKRA (Crown Chakra)
Are you a believer in God?
Are you a believer in God?
Yes
No
Are your mad at your father?
Are your mad at your father?
Yes
No
Are you worried for your father?
Are you worried for your father?
Yes
No
Do you think you are right often?
Do you think you are right often?
Yes
No
Do you have problems with your sleep?
Do you have problems with your sleep?
Yes
No
Thank you!
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