Please check off and describe in detail, the problems/concerns
which apply to you and relate to your weight loss goals:
Guilt, shame, feeling unattractive, feeling inadequate, fear of
binging, jealousy, feeling weak, avoidance of specific people
places, things, hopeless regarding weight loss, feeling desperate,
feeling held back, obsessive thinking about food and weight,
judgmental of self, cravings. Not being in control, thoughts of
deprivation, eating to manage stress.
Describe present sources of stress. How do you typically manage
What are your specific weight loss goals?
Weight loss of ____ pounds, the ability to enjoy food, improved
self-esteem, spending less time thinking about food, less guilt,
less fear, other:
Describe past attempts to lose weight and maintain weight loss.
What was your lowest weight? What was your highest weight? At what
weight do you feel attractive? What is a realistic weight goal?
What will weight loss accomplish for you? describe a fantasy
related to your weight loss goal.
In your opinion, what contributes to your weight problem?
How often do you weigh yourself? Describe your reactions.
Do you have exercise goals?
Describe past attempts to exercise.
Has behavior modification been helpful in the past? Please specify
what helped and what didn’t.
Have affirmations, positive self-talk, stress management or
cognitive restructuring been helpful? Please specify
Is it possible that your present weight protects you from unwanted
Is it possible that a traumatic event is related to your weight
Please list any past or present medical conditions, medications
and supplements you are currently taking.
Describe your reactions to the idea of starting a "diet".
Describe the most difficult times of day.
Describe the emotions, situations, people, places etc which are
How does your present weight problem effect your emotions,
behaviors, relationships and professional pursuits?
What personal traits and accomplishments do you feel proud of?
How would a good friend describe you?
Do you live alone or with others? Does this help or hinder your
weight loss efforts? how?
In your opinion, what needs to be done to accomplish your weight
On a scale of 1 to 10, where ten is
the most upsetting, how upsetting is your present weight problem?
List what you may typically eat and drink on both a “good” day and
a “bad” day.
Other pertinent information regarding your weight loss goal:
What are you hoping that hypnosis
will do for you? Do you have any specific concerns or questions
regarding hypnosis treatment?
Feel free to compose motivational phrases or describe motivational
images which may be incorporated in your session. Indicate which
words might be counterproductive.
Use additional paper if necessary and email to my private
Plymouth Meeting, Pennsylvania
Serving Philadelphia, Philadelphia Suburbs, and The Main Line