Download PDF for Printer friendly version
Download PDF
printer friendly version
       
 
Name :
  
       
 
Age :
  
       
 
Occupation:
  
       
 
Phone :
 
       
 
Email :
  
       
  1. Do you currently have a medical condition(s)?   Yes     No
     
        a. If yes, briefly describe:  
     
        b. Please list any medications, vitamins/minerals or supplements you take, if any:  
       
  2. Have you ever seen a mental health practitioner (i.e. therapist, psychiatrist, etc.)?   Yes     No
       
       a. If yes, please describe what was helpful or not:  
       
  3. Have you ever experienced hypnosis (or guided imagery) before?   Yes     No
     
      a. If yes, when?  
       
      b. What was the experience like for you?  
       
  4. Do you have any concerns about experiencing hypnosis?   Yes     No
     
      a. If yes, describe your concerns:  
       
  5. Are you currently in a relationship?   Yes     No
       
  6. Do you have any children?   Yes     No
     
       a. How many? Ages?  
       
  7. What is your current height and weight?  
     
  8. Do you have an ideal weight?   Yes     No
     
        a. If yes, what is it?  
     
  9. Why do you want to release weight now?  
     
  10. Please check any of the boxes that you feel contribute to your difficulty releasing weight.   I start out well but it gets too difficult to stay motivated.
      I eat according to my emotional state (bored, lonely, happy, sad)
      I have difficulty tolerating cravings
      I have problems finding the time and energy to get and stay healthy
      Lack of confidence or self-esteem, e.g. "I don't feel worthy or value myself enough to make the effort
      I don't value my accomplishments so I self-sabotage
      I think things like, "I deserve a treat,"  "It's not fair that others get to eat and stay thin, "or "I've had a rough day/week/year"
      I follow childhood patterns like sweets for being good or being deprived of foods to punish
      Other (please describe):