HEALTH BY DESIGN CLIENT INTAKE QUESTIONNAIRE
FOR HYPNOTHERAPY
Part I: General Information
Main Contact
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Belgium
Belize
Benin
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Botswana
Brazil
Brunei
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Cape Verde
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Chad
Chile
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Christmas Island
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Cook Islands
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Cote d'Ivoire
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Dominican Republic
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Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
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Iran
Iraq
Ireland
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Japan
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Kenya
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Laos
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Luxembourg
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Macedonia
Madagascar
Malawi
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Maldives
Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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Uruguay
Uzbekistan
Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Current Website URL (if applicable)
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PART 2: HYPNOTHERAPY INTAKE
GENERAL
MAIN REASON FOR HYPNOTHERAPY TREATMENT
HOW LONG HAS THIS BEEN A CONCERN
MEDICATIONS
YES
NO
N/A
VITAMINS
PLEASE LIST MEDICATIONS/VITAMINS
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PART 3: HYPNOTHERAPY INTAKE CONT...
PSYCHOSOMATIC SYMPTOMS
SLEEP QUALITY OVERALL
1
2
3
4
5
Poor
Good
1 is Poor, 5 is Good
SLEEP
FALL ASLEEP EASILY
DIFFICULTY FALLING ASEEP
WAKE UP AFTER A FEW HOURS
DIFFICULTY FALLING BACK TO SLEEP
DIFFICULTY STAYING ASLEEP
NO CONCERN
DO YOU HAVE HEADACHES
Yes
No
HEADACHE SEVERETY
1
2
3
4
5
Bearable
Unbearable
1 is Bearable, 5 is Unbearable
IF YOU ANSWERED YES TO HEADACHES - PLEASE DESCRIBE
DO YOU HAVE HEART PALPITATIONS?
YES
NO
SOMETIMES
NEVER
HEART PALPITATIONS DETAILS
OVERALL DIGESTION
0
1
2
3
4
5
No Concern/Discomfort
Highly Concerned/Discomfrot
0 is No Concern/Discomfort , 5 is Highly Concerned/Discomfrot
HOW IS YOUR TUMMY/ DIGESTION
DO YOU HAVE FATIGUE
FATIGUE LEVEL
0
1
2
3
4
5
No Fatigue
Severe Fatigue
0 is No Fatigue, 5 is Severe Fatigue
DO YOU HAVE STRESS SWEAT
HOW ARE YOU IN LARGE CROWDS
COMFORTABLE
UNCOMFORTABLE
OVERWHELMED
ANXIOUS
N/A
ANXIETY LEVEL IN LARGE CROWDS
0
1
2
3
4
5
No Anxiety
Severe Anxiety
0 is No Anxiety, 5 is Severe Anxiety
DO YOU HAVE SELF CONFLICT
YES
NO
SOMETIMES
N/A
IF YES TO SELF CONFLICT, PLEASE DESCRIBE
DO YOU EASILY GET NERVOUS
YES
NO
SOMETIMES
RARELY
IF YES, PLEASE DESCRIBE
DO YOU EASILY GET ANGRY
YES
NO
SOMETIMES
RARELY
WHAT ARE YOUR ANGER TRIGGERS
DO YOU HAVE DEPRESSION
YES
NO
DIAGNOSED
N/A
DEPRESSION DETAILS
DO YOU HAVE SUICIDE THOUGHTS
YES
NO
SOMETIMES
N/A
IF YES, PLEASE PROVIDE MORE INFORMATION
DO YOU HAVE FEAR
YES
NO
N/A
FEAR DETAILS
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PART 4: ADDITIONAL INFORMATION
HYPNOTHERAPY INTAKE
OPTIONAL: PLEASE PROVIDE ANY OTHER INFORMATION THAT YOU'D LIKE TO SHARE HERE
THANK YOU FOR COMPLETING THIS INTAKE FORM MELANIE WILL CONTACT YOU SHORTLY TO SET UP YOUR TREATMENT PLAN
MELANIE POULIOT - CLINICAL HYPNOTHERAPIST
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