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Hypnosis Questionnaire

Please fill out the following form, giving the first thought that comes

to mind for each question. All information is kept strictly confidential.

Todays ate!""""""".

Age!"""""""""

#e$!

% &

% '

(ccupation!"""""""

&arital #tatus!"""""""".

:

). Have you ever *een hypnoti+ed

o yes

o no

-. hat is your previous e$perience with and opinion a*out hypnosis

"""""""""""""""""""""""""..

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""""""""""""""""""""""""./. Have you ever seen anyone hypnoti+ed

o yes

o no

0. o you *elieve hypnosis can help you

o yes

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o no

1. hat is the main goal that you would like hypnosis to help you

with 2i.e., weight loss, smoking cessation3

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4. hat are your smaller goals 25su*6goals73 that you want to

accomplish to help you with your main goal 2i.e., quitting 8unk food for

weight loss or handling stress *etter for smoking cessation3

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9. Have you ever walked or talked in your sleep

o yes

o no

:. Have you ever awakened like you couldn;t move or speak

o yes

o no

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o yes

o no

)1. Are you a*le to follow directions

o yes

o no)4. Are you a*le to get in touch with your emotions easily

o yes

o no

)9. o you *elieve that it;s possi*le for a person to *e healed *y the

power of his or her mind

o yes

o no

):. Have you ever wished that you could avoid taking any

medicationo yes

o no

)f you were to imagine sucking on a sour, *itter, 8uicy, yellow lemon,would your mouth *egin to water

o yes

o no

--. o you have nightmares

o yes

o no

-/. Are you currently under the care of a Psychiatrist

o yes

o ?o

-0. How strongly would you rate yourself from ) 2very weak3 6)=

2very strong3 with how well you feel you can engage in the

following!

a3 @eing a*le to rela$ when you choose to"""""""

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*3 isuali+ing scenes or situations in your mind"""""..

c3 Becalling recent memories from the past"""""

d3 Becalling distant memories from the past"""""""

e3 Telling yourself to do certain things in your

mind"""""..

Thank you for your time C Have a great day C