Name
*
First Name
Last Name
Date
/
Month
/
Day
Year
Date
Street Address
City
Zip
Primary Phone
Is eliminating your problem a priority for you?
Yes
No
Does your problem affect you when you are under stress?
Yes
No
Do you feel your problem controls you?
Yes
No
Are you embarrassed by your problem?
Yes
No
Does your problem affect you professionally?
Yes
No
Does your problem affect your social life?
Yes
No
Does your problem affect your activities?
Yes
No
Does your problem make you feel tired and run down?
Yes
No
Do you exercise?
Yes
No
If yes, what type?
How often?
Daily, weekly monthly
Secondary Phone:
Email
example@example.com
Age
Sex
Height
Weight
Date of Birth
/
Month
/
Day
Year
Date
Occupation
Marital Status
Single
Married
Divorced
Widow/Widower
Favorite Hobbies
What benefit do you want from hypnosis?
Please briefly describe the nature of your problem:
How long have you had this problem?
What is the most difficult part of eliminating your problem?
Do you have any concerns about hypnosis?
Yes
No
If Yes, please explain
Are you currently under the care of a physician?
Yes
No
If yes, what is the physician's name?
Did your doctor recommend that you use hypnosis?
Yes
No
Legal Name
*
Signature
*
Date Signed:
*
/
Month
/
Day
Year
Date
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