Weight Loss Questionnaire

Please down load and send to ajclifecoaching@btinternet.com

Confidential Weight Loss Questionnaire.

Date:
Name:*
First
Last
Address:*
Phone:
Mobile Phone:*
Phone Number
E-mail:*
Website
Date of birth:*
Sex:*

Male

Female

Marital/Relationship Status:

Married

Divorced

In a relationship

Single

Recently broke up

Number of children:
Occupation*
Religion?
Parents

Father

Mother

Siblings?*
Were/are other members of your family overweight? (tick where appropriate)

Mother

Father

Siblings

Spouse/Partner

Children

Specific information about family, childhood, marriage, relationships, sexuality:
Are drugs or alcohol a problem*

YES

NO

If you answered YES to the above please provide details:
Are You A Smoker?*

YES

NO

How would you describe your Sleep / Relaxation?*

GOOD

AVERAGE

BAD

How did you hear about us?
Have you ever been hypnotised before?*

YES

NO

If you answered ‘YES’ to the above, by whom and why? Do you think you were hypnotised and why?
 MEDICAL HISTORY
Please let us know by ticking the box, if you have been under the care of a doctor in the last 12 months for any of the following:

Emotional/Psychological Issues

Medical/Physical Issues

If you ticked either of the above please provide us with more details:
Doctors name:
Doctors Surgery Address:
Details of any prolonged illness:
Have you been treated for (mark if yes):

Heart Issues

Diabetes

Epilepsy

Psychosis

Are you currently taking medication?*

YES

NO

If you answered ‘YES’ to the above, please provide details:
QUESTIONS ABOUT YOUR WEIGHT LOSS GOALS
Target weight*
Age you were last at your target weight?*
Target Dress Size (women)
Target waist size (men)
MOTIVATION 1
MOTIVATION 2
MOTIVATION 3
Weekly exercise activity:*
Choose one;
NONE
LIGHT
MODERATE
FREQUENT
INTENSIVE
Weekly alcoholic consumption?*
Problem Foods or Drinks*
e.g. cakes, coca cola etc.
Are there any foods you are allergic to?*
Any previous efforts to resolve the problem?*

YES

NO

If you answered ‘YES’ to the above what did you do and what were the results? e.g. slimming world, lost 3lb…
Would there be any negative consequences for achieving your goal?
Questions you may have:
Question 1
Question 2
  • I hereby confirm that, to the best of my knowledge the information I have given is correct.
  • I am aware that the hypnotherapist/consultant provides no diagnoses about disease and will not make promises of cures or of healing and I attend the appointment with this understanding.
  • I acknowledge that all client and therapy content is strictly confidential
  • I understand that visiting a therapist does not replace medical advice or treatment. I can confirm that the therapist/coach has not advised in any form against seeking or continuing medical or other professional advice or treatment, nor have they advised on the cessation or reduction of prescribed medication.
  • I GIVE PERMISSION FOR WRITTEN CONTACT BETWEEN THERAPIST/COACH AND MY GP.
  • No audio/video recording of the session may be allowed. I can however, request a video recording be made of the session for mutual protection and held securely for future reference.
By Signing Below I acknowledge and agree to ALL OF THE ABOVE.

 

:)

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