Name

Date

Email Address

Address

City

State

Zip

Home Phone

Cell Phone

Height

Weight

Age

Sex

Marital Status

College Degree

Major

Occupation

Favorite Hobbies

Do you feel stress? Explain

Are you currently under a physicians care?

Do you get angry often?

Are you happy? If not, why?

Have you been hypnotized before?

What were the results?

How long have you been overweight?

How much weight have you decided to lose?

How many times have you failed at weight loss?

Do you suffer from uncontrollable cravings? Explain:

Do you feel out of control? Do you feel out of control? YES NO

Are you embarrassed about your weight? Are you embarrassed about your weight? YES NO

Is successful weight loss a top priority? Explain:

Did you know hypnosis is 100% safe? Did you know hypnosis is 100% safe? YES NO

What is the exact weight you’re going to be?

Does your family support your weight loss efforts? Does your family support your weight loss efforts? YES NO

Has being overweight caused you pain and suffering? Has being overweight caused you pain and suffering? YES NO