Weight Loss QuestionnaireWeight Loss Questionnaire Name Name First First Last Last Date Address Home Phone Work Phone Email Date of Birth Age Gender MaleFemaleNonbinary Marital Status Single Married Widowed Divorced Height Weight Goal Weight Goal Size Favorite Hobby Occupation How did you hear about us? WatermarkColumbia.com Web SearchWeb Search GoodTherapy.org Facebook/TwitterFacebook/Twitter Referral (name)Referral (name) PsychologyToday.com Radio (station)Radio (station) OtherOther Next Are you currently under the care of a physician? Yes NoDid your doctor recommend that you use hypnosis? Yes No Physician's Name Have you ever been diagnosed with epilepsy or had seizures of any kind? Yes NoDo you exercise? Yes No How often? Do you feel stress? Yes No Explain What worries you most? What do you want from hypnosis? What do you expect from hypnosis? Did you know that hypnosis is 100% safe? Yes NoHave you ever been hypnotized before? Yes No Results Why did you choose us for hypnosis? What would you consider your ideal weight? How much weight do you want to lose? How many times have you failed at weight loss? What other methods have you utilized in order to lose weight? Does your weight make you physically uncomfortable? Yes No Explain Are you embarrassed about your excessive weight? Yes NoDoes your excessive weight limit you or your activities? Yes No How many times a year do you diet? Do you binge eat? Yes NoDo you suffer from uncontrollable cravings? Yes No Explain Do you feel food controls you? Yes NoDo you eat because of emotions? Yes NoDo you eat between meals? Yes No Describe your daily eating behavior Do you feel your eating behavior is normal? Yes No What new activities will you become involved in? Is successful weight loss a top priority? Yes NoDo you believe weight loss has to be painful? Yes NoWill you purchase a new wardrobe when you lose weight? Yes No How fast do you want to be slim, trim and fit? When? Does your family support your weight loss efforts? Yes No What do you remember about being your ideal weight? Is your family excited about your weight loss with hypnosis? Yes NoHas being overweight caused you pain or suffering (physical or emotional)? Yes NoDoes being overweight limit your social life? Yes No Explain Do you feel tired, run down and out of energy? Yes NoWhat is the most important element in deciding to use our services? Effectiveness: "My results are my top priority" Time: "I want results quickly" Service: "I need extra support along the way" Affordable: "What you charge is my concern"Can you remember being your ideal weight? Yes No Date If you are human, leave this field blank. Submit
