DALLAS HYPNOSIS CONSULTANTS

Weight Loss Program Questionnaire

Thank you for choosing Dallas Hypnosis Consultants. We are specialists at helping you make the kinds of changes you need to make in your life, so you can become slimmer, healthier and happier with yourself. Our hypnosis program is very effective, because it is tailored to your needs. Please take a few minutes to fill out this form, so we can serve you better. The hypnotist will use it during your meeting in order to custom design an appropriate and effective hypnosis program to meet your goals.

Name __________________________________________ Date _________________________

Approximately, what is your weight now? ____________ What is your goal weight?__________

In your opinion, why are you not achieving and maintaining your desired weight or size at this

time?_________________________________________________________________________

______________________________________________________________________________

Please place a mark next to the statements below that are true for you. Then, go back through the list, and circle the four or five changes that you would like to make to help you the most toward your weight loss goal.

____ I would like to exercise more.

____ I would like to drink more water.

____ I would like to feel more motivated to consistently do the things I need to do to become

slimmer.

____ I would like to really believe that I can lose weight.

____ I would like to be able to reduce the amount of food I eat at meal time.

____ I would like to stop snacking between meals.

____ I would like to be able not to snack so much at home, because that is one of the main

problems (i.e., eating while reading, watching TV, or working at the computer).

____ I would like to be able not to snack at work, because that is one of the main problems.

____ I would like to be able to resist salty or sweet snacks, or just eliminate them completely.

____ I would like to cut down on the amount of alcohol I drink. Those drinks are so fattening.

____ I think I am over weight because of my mother or father, etc.

____ I normally eat breakfast, but this has not always been true. I have heard “breakfast” is the

most important meal of the day. But it seems (to me) if I eat breakfast, I am hungry all

day long.

____ Sometimes, I eat when I am not really hungry. What percent of food do you eat because

of true hunger? ________%

____ I sometimes eat when I feel (boredom, depression, anxiety, stress, loneliness, or sad, etc.)

____ I sometimes eat when I feel happy and want to celebrate, or to be social, or just because

the clock says that it is time to eat.

____ I have another reason I eat in a way that is preventing me from becoming as slim and lean

as I would like to be.

Why I Want to Be Slim and Healthy

Now place a mark next to some of the reasons you want to lose weight. You can add other reasons at the end of the list. After all, the purpose of this form is to learn more about how we can help you.

____ Better health. ____ More energy.

____ Fit into those clothes I wish I could still wear. ____ Improve my career opportunities.

____ Make the clothes I have fit better. ____ More self-confidence.

____ Improve my relationship. ____ Feel better about myself.

____ Shopping would be more fun. ____ Look and feel better in a swimsuit.

____ I want to look good for a special occasion (i.e. wedding or vacation). _________________

____ Almost everything in my life would be better.

____ If I lost this weight, I would feel more self-confident and be a better example to others.

____ Another reason or reasons not on the list. _______________________________________

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