Hypnotherapy Consultation | Tucker, GA

First Name

Last Name

Email

Work Phone

Cell Phone

Home Phone

Street

City

ST

Zip

Age

Date of Birth

Marital Status

Single

Married

Divorced

Other

Partner’s 1st name

Field label

High school graduate?

College graduate?

Advanced Degrees?

School

Graduate Degrees

Primary Occupation

Title?

Do you enjoy what you do?

If not, what would you prefer to do?

How did you learn about Jim Colton Hypnosis?

Reason for visit

How long have you experienced this?

With whom have your worked on this?

How familiar are you with hypnosis?

Very Much

Some

Not at all

What hobbies do you have?

What exercises do you enjoy?

What is your favorite place in the world to vacation?

Why?

IMPORTANT: Check all applicable symptoms or issues

IMPORTANT: Check all applicable symptoms or issues

Anxiety

Digestive Problems

Insomnia

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Which of the following medications or supplements do you take?

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Antibiotics

Anti-depressants

Blood thinners

Vitamins

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Heart Medicine

Chemotherapy

Sleeping Pills

Insulin

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Laxatives

Pain Relievers

Sedatives

Other (Describe below)

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This information is needed to help you accomplish your goals. Please fill it out completely.

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The following are part of my life to the degree indicated

Alcohol

None

Small

Med

Large

Caffeine

None

Small

Med

Large

Nicotine

None

Small

Med

Large

Stress

None

Small

Med

Large

Sugar

None

Small

Med

Large

Exercise

None

Small

Med

Large

Fun

None

Small

Med

Large

Meditation

None

Small

Med

Large

New Field:

Are you afraid of heights?

Roller coasters?

Water?

Describe any other fears (public speaking, sales call reluctance, meeting new people, etc.) you may have

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Do you tend to over-analyze?

Procrastinate?

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Do you think you could be sabotaging your relationships or efforts at success?

What other behavior do you engage in that is detrimental to your health?

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Weight Loss

When do you first eat daily?

Are you a night feeder?

On what foods do you snack?

In what activities are you involved when you snack?

What foods do you enjoy?

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Do you eat in your car?

At your desk?

While watching TV?

Do you consume alcohol while eating?

In what rooms of your house are you most likely to eat?

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Smoking

Do you want to quite or does someone else want you to?

How long have you been smoking?

Why do you want to quit?

Are you a “secret” smoker” or do you smoke around others?

How many packs a day?

What time do you have your first cigarette?

What are you doing at this time?

Do you smoke when you drink coffee?

Alcohol?

Where do you smoke (car, boat, deck, bar)?

What activities do you engage in when you smoke?

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Alcohol

What led you to come to see us about drinking?

Do you feel you drink too much?

Do you drink with most evening meals?

Where are you when you drink?

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• The undersigned requests Jim Colton, provide hypnotherapy and/or self-help education services.

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• The undersigned understands they are responsible for all charges they incur through working with Jim Colton AKA You

Unlimited.

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• Behavioral change requires effort on your part. As we cannot guarantee that an individual will make the effort to change behaviors, there will be no refunds beyond the first session.

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• The undersigned agrees to give at least 48 hours’ notice in advance when cancelling an appointment.

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• Failure to do so requires payment for that appointment.

Date

Signature

Health History Form

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