Weight Loss Questionnaire
sartainhypnotherapy.com
Name Address
Phone Email
Why do you want to lose weight?
How many pounds do you desire to lose?
Have you dieted before? How long?
How much weight did you lose from the diet?
How long did you keep the weight off?
Do you take prescriptions? Please list:
Do you have any medical conditions?
Are there particular foods you crave?
Are there certain times of the day you eat more amounts of food or junk food?
If so, please list times and foods:
Are you an emotional eater?
Do you eat when you are: bored, frustrated, angry, apprehensive, socializing, celebrating, comforting etc…?
Does your family have a history of obesity?
Is your spouse over weight?
How long have you had a weight problem?
Are you ready to become slimmer and healthier now?
Debora Sartain, Certified Hypnotherapist
717 367-8591
Elizabethtown, Pa 17022
Email: debhypnotist17@msn.com