Weight Loss Questionnaire

First Name

Last Name

Telephone

Address

Address Line 1

Address Line 2

City

Postcode

Have you had hypnotherapy before?

Age

Are you on medication?

Please indicate which medication(s)

How would you like to change your eating habits?

When do you overeat?

What emotions are you experiencing when you overeat or plan to overeat?

What foods do you eat too much of?

Do you consume too many sugary drinks and if so which drinks?

Are there any foods or drinks which you would like to eliminate from your diet? If so, which foods or drinks?

What healthy foods and drinks do you enjoy?

Do you eat three regular meals a day? Are these meals healthy or do they consist of foods that you would like to change?

Do you binge eat and if so how often and in what situation?

How do you feel when you know you have overeaten?

Are you worried about your health and if so why?

How do you feel about yourself and the way you look?

How would you like to look and feel about yourself?

What are the benefits for you in losing weight?

Are you a vegetarian or are there any foods you are unable to eat?

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