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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
cisco
DATE OF BIRTH:
September 16, 1957
PHONE NUMBER:
9788044185
ADDRESS:
EMERGENCY CONTACT NAME & NUMBER:
Theresa Borges
9789732134
RELATIONSHIP STATUS:
wife
OCCUPATION:
retired
How did you hear about us?
From a relative
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
no
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
no
Are you currently taking any prescribed medication? If yes, please list.
Tamsulosin 40mg capsules, Metoprolol ER Succinate 100mg tabs, Atorvastatin 80mg tabs and Isosorbide 30mg tabs and baby aspirin daily
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
no
ADDICTIONS:
ANXIETY
EATING PROBLEMS
Food/Diet, Weight Problems
DEPRESSION
CAREER ISSUES
CONCEPTION PROBLEMS
PAIN CONTROL
Mobility, Inflammation
RELATIONSHIPS
DIABETES
Have you ever had serious thoughts of harming yourself or others?
no
Do you or any member of your family have a history of epilepsy?
no
Have you ever been hypnotized before?
yes
What areas of your life would you like to work on?
diet
What is the biggest challenge that you wish to work on during your session?
diet
Have you tried to do anything about this before now? If so, what?
fast
EXPECTATIONS:
don't expect anything
Anything else I should know?
no
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
if I have too
Are you 18 years of age or older?
Yes
AGREE TO TERMS:
I agree to all of the terms and conditions listed above.
WEIGHT CLIENTS
What is your ideal weight?
180
When was the last time you were at or near this weight?
1999
What is the heaviest and lightest you have ever been?
250 150
If you could design a relationship with food, what would it be like?
good friend
Can you leave food or throw it away?
can do either
Do you eat when you are bored, stressed or tired, or experiencing another emotion?
I eat when hungry
Do you use food to comfort yourself?
no
Do you have good and bad days?
no difference between the two
Are your eating resolutions harder to stick to when you are out with friends?
no
Were you given chocolate/cakes/trigger foods when you were growing up?
no
Were any foods forbidden to you growing up?
no
Do you prefer to cook or eat out?
no preference
24-Hour Recall
sausage and cheese wake up rap, Tuna fish sandwich and chicken w vegetables for diner
Is this a typical day for you?
lunch and dinner only