Weight Loss Form - Therapy & Hypnosis with Diana Levy

Name *

Name of a spouse/partner (if any)

Names and ages of the children/dependents (if any)

What is your current weight?

What is your desired weigh goal at the end of 12-week program?

What kind of specific WL would get you excited, in other words if there was no limit of any kind and you could achieve any goal in regard to WL, what would that be, what would be the “magic number”, the ideal weight?

How much time do you think you need to reach that?

Would you like to achieve that?

Why now?

What could be the reasons why you would NOT want to achieve that?

Please list all the reasons you can think of, why you want to reach your ideal overall weigh goal, the “magic number”:

What benefits you will receive after achieving your ideal overall weigh goal?

How will you feel weighing that ideal overall weigh, standing on the scale, and seeing that “magic number”?

Briefly, what is your weight history:

Briefly your prior attempts and results in weight loss (age, motivation, what worked, what didn’t):

Briefly describe your typical meals on the daily basis:

Do you travel a lot and if applicable is it difficult to eat healthy while on the road?

What in your opinion triggers you to snack unnecessarily and/or overeat?

Briefly, what was your relationship with food growing up?

What weight loss programs have you participated in, if any (zone diet, weight watchers, nutrisystem, diet pills, surgery, juicing... etc)?

Have you maintained a weight loss for more then a year after any of these programs?

What did you learn about yourself from these programs?

Do you have any food allergies?

Are there foods that you absolutely dislike?

Are there any foods that you can be easily tempted by, currently?

What is your alcohol intake on the weekly basis?

How do you feel about giving up alcohol for 3 months?

Have you ever done 24h water fast, if yes how was your experience?

Have you ever done intermittent fasting, if yes how was your experience?

Do you exercise regularly, if yes what is your weekly routine (in few words)?

Would you consider yourself someone who eats healthy foods at least 90% of the time?

Would you consider yourself someone who enjoys physical activity at least 90% of the time?

With WL, what is your biggest challenge, emotionally/mentally?

With WL, what is your biggest challenge, habitually/behaviorally?

What’s your least difficult challenge, something you can do easily, give up easily?

Who else lives in your household and would that person(s) be supportive of your weight loss journey?

What is your normal typical caloric intake daily (approximate, if you know):

What is your maintenance caloric number, the amount of calories your body need to survive based on your size, gender and age (your basic caloric needs when body is at rest, you can use any of BMR calculator online to find out):

How much do you know about nutrition?

Do you smoke?

Do you suspect or have or had in the past any eating disorder?

Please list fears, major issues (mental, emotional), if any:

Do you have any compulsive tendencies?

Please list any health issues (physical), if any:

Do you have any physical limitations?

Please list two favorite colors

Please list two favorite places

Please list two of your favorite pastime/hobbies

Please list two of your most important lifetime goals

Please list two of your most important WL related goals

Why do you think hypnosis for WL will work for you?

One thing I feel guilty about is:

What is important to me is:

I am happiest when:

I get angry when:

I get saddened by:

One of the ways I can help myself but don’t yet, is:

Its hard for me to admit:

I am a person who:

A mother should:

A father should:

A friend should:

Mention few most important memories and the age you experienced them:

What specific behaviors would you like to change that will contribute to your having a better quality of life?

What would you like to start doing?

What would you like to stop doing?

Do more of:

Do less of:

How do you see yourself in 3 months’ time, how would you look, feel, what you be doing?

What would have to change for that to happen?

What are your values in life?

What are some of your beliefs about WL?

In general, what motivates you?

One of the things I feel proud of is:

Do you have any negative conditions that affect your WL progress?

Do you have any additional concerns?

Do you observe any meditative practice?

How do you sleep in general?

What do you do for Self-Care in general?

What kind of successful Self-Soothing techniques that you are using currently?

Are some of the Self-Soothing techniques that you are using currently involve food?

How committed you are to this particular WL journey?

Are you ready for it this program to work for you?

If you were completely honest with yourself about why you haven't shed the unwanted weight yet, what would you answer?

Write out your draft Ultimate WL Statement (in present tense, as if the goal was already reached, include how it makes you feel, reasons, benefits). This can be corrected as time goes by. Example: “I am excited to finally weighing _____ lb/kg. I feel confident and proud, self-assured seeing myself in the mirror in these size jeans. I have more energy than ever. I am the fittest I have ever been, and I am completely committed to my new lifestyle which I happen to enjoy very much.”

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Weight Loss (WL) Questionnaire for 12-week program (Confidential)

Some of the questions are specific, some are vague and open for interpretation, please answer to your best ability.

It can take about 15-30 min to complete.

This is your first investment into a new, Calmer & Fitter You.