Hypnosis for Weight Loss Intake Form

HYPNOSIS EVALUATION FORM - WEIGHT LOSS & GASTRIC BAND HYPNOSIS

The following questionnaire is a comprehensive look at your health & lifestyle. It will take about 15 TO 20 minutes to complete and is imperative for successful Hypnosis sessions. Please allow yourself the time to complete without disruption. The form will not auto save to come back to later.
Full Name

First Name Last Name
Gender

Male Female Other I do not identify
E-mail
Phone Number

Area Code Phone Number

Your diet and relationship with food
How many meals a day do you eat?: *

3+ 2 1 0
Are you a Vegetarian or vegen: *
If yes, please tell us why you chose this path.
Have you started menopause?: *
Planning to have a baby in the next 3-6 months: *
Pregnant or breastfeeding: *
Give us an idea of your average day for meals and food. *
Breakfast, mid morning, lunch, mid afternoon, Supper, evening snacks
Do you snack between meals? If so, what do you snack on? *
Chips, sugar, carbs etc
Do you ever get up during the night to eat something? *

Yes No
If you overeat? Which foods would you like to cut down on or eliminate?
Do you drink pop (even sugar free) or sugar drinks? If so, how many a day?

Weight Gain History
At what age to you recall being at your "ideal" weight?
Leave empty if you have not ever felt you have been.
What emotions do you associate with this period in your life?
Ex: guilt, comfort, punishment, contentment etc
What changed in your life when you began gaining weight?
Divorce, parental separation, child birth, death, trauma etc
What is your goal weight?
Do you diet frequently?

Yes No
If yes, in your own words; what stops you from succeeding when you diet?
Social events, fear, criticism, self talk etc

Grocery Shopping
Who does the food shopping in your house? *
Who prepares and cooks the food? *
Do you often leave food on your plate? *
Do you regularly finish off other peoples food?: *
Please tick all foods that you enjoy:

Sweet Foods Starchy Foods Savory Foods Fatty Foods Fresh Fruit Grilled Foods Fresh Vegetables

You're almost done. Great job!
Please tell us anything else that you may feel important or you feel is holding you back from achieving your weight and health goals. Feel free to be as specific as you need to be.
Would you like us to E-mail you a copy of your form? *
Your Preferred E-mail Address *
Signature - you may use your finger on your screen or your computer mouse.

Clear
The information contained within this form will be held in confidence and in accordance with PHIPA/PIPEDA and HIPAA requirements.
The information will be utilized in partnership with Deanna L. Byrne CHt, CMT, mNLP, Master Life Coach, and Hypnotherapist for your coaching and hypnosis sessions.
You will also be required to submit our teleconsult consent form prior to any virtual meetings or telephone calls.
Should be Empty:

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HYPNOSIS EVALUATION FORM - WEIGHT LOSS & GASTRIC BAND HYPNOSIS