MTU Hypnosis - Weight Loss Form

MTU Hypnosis - Weight Loss Form
Name*
Home Phone
Format: (000) 000-0000.
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Accept Texting?*

YesNo
E-mail*
example@example.com
Address*

Address

Street Address Line 2

CityState / Province

Zip
Emergency Contact*
Phone*
Format: (000) 000-0000.
Age*
Birthdate*

MonthDayYear
Date
Marital Status*

SDSep.Wid.Married
If children, what are their ages?
Highest education level completed*
Occupation*
Doctor’s Name*
Phone*
Format: (000) 000-0000.
Complete Address*
Are you under a doctor’s care now?*

YesNo
Indicate any current health problems - any medications currently taking & their purpose
Have you ever been psychologically treated for an emotional/behavior problem?*

YesNo
If yes, are you currently receiving treatment or counseling?

YesNo
Provider name
Phone
Format: (000) 000-0000.
Complete Address
Do you have light sensitive epilepsy?*

YesNo
Do you wear contact lens?*

YesNo
Dentures?*

YesNo
Do you exercise?*

YesNo
How often?*
What type?
Do you get angry often?*

YesNo
Are you happy? (If not, why?)*
What worries you most?*
If you have ever been hypnotized - indicate private or group/purpose/result?*
Do you know anyone personally who has used hypnosis to improve or change his or her life?*
How did you find MTU Hypnosis?*
Why did you decide to call on MTU Hypnosis?*
If you have any fears, concerns, or questions about hypnosis — please describe.
Did you know hypnosis is 100% safe?*

YesNo
24.List your e-mail address if you are interested in receiving our e-newsletter
example@example.com
Select the most important element in deciding to use our services.*

Effectiveness ( your results )Service ( how we respond to your needs )Time ( how fast you get results )Affordable ( what we charge )
How long have you been overweight?*
How many times have you failed at weight loss?*
What previous efforts have you taken to lose weight in the past?*
How much weight have you decided to lose?*
Current weight*
Height*
Desired Weight*
By date*

MonthDayYear
Date
Current Pant size*
Desired Pant Size*
Current Top Size*
Desired Top Size*
Which are applicable due to your excess weight?*

Affects how I look, feel unattractiveAn Unwanted ExpenseConfidence and Self Esteem IssuesDiscomfort, Pain, SufferingEmbarrassmentFamily/Work ProblemsFeeling SadFeeling that food controls meLimits on Social LifeLimits what I can wearLow EnergyRun Down FeelingSnoringTirednessWinded Breathing
Activities limited or abandoned such as
Health problems such as
Do you suffer from uncontrollable cravings (explain)?*
Do you feed emotions with food (explain)?*
Is successful weight loss a top priority (explain)?*
What would you most love to be seen wearing?*
What new activities will you become involved in after you lose weight?*
Are other family members overweight?*
Do you believe weight loss has to be painful?*
Do you believe weight loss can be enjoyable?*
Does your family support your weight loss efforts?*
Can you remember being your ideal weight and if/so -when?*
What are all the reasons why you think you are overweight?*

AlcoholExtra HelpingsFeeding AngerFeeding AnxietyFeeding BoredomFeeding LonelinessFeeding PainFeeding SadFeeding StressFeeding TiredGeneticsHormonesJunk FoodLack ExerciseLate Night EatingLow ConfidenceNeed a RewardPop ConsumptionPortion SizeRebellingSnackingOther
What 3 to 5 positive benefits do you get by eliminating your excess weight? Example: I am more confident and at ease, even when dealing with stressful situations.
a*
b*
c*
d
e
Where applicable, check any other issues you have been dealing with and/or would like to resolve.

AlcoholismAngerAnxiousBed WettingCancer/Chemo/RadiationDrug AddictionFear of Flying/HeightsFeeling OverwhelmedGagging ReflexGamblingHabit ControlHigh Blood PressureIBSImproved ConcentrationInfertilityInsomniaJealousyJob Interview AnxietyLearning/ADDMedical/Dental Procedures Performance AnxietyMemory ImprovementMigrainesMotivationNail Biting/PickingNervous StomachNervous TicsOCDOrganizational SkillsOver-Healing/ScarringPain ManagementPanic AttacksPre/Post SurgeryProcrastinationPTSDPublic SpeakingRelationship IssuesSalesSelf ConfidenceSkin ProblemsSmoking CessationSports ImprovementStress ManagementStutteringTeeth Grinding/Jaw ClenchingTension HeadachesTest Taking/Study HabitsTime ManagementTobacco ChewingVappingVertigoVisualizationWartsWeight ControlNONEOther
First & Last Name*
Signature*
Date*

MonthDayYear
Date
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