A New Life Hypnotherapy Center - Hypnosis Diet Questionnaire

services for a better life start here...
Phone: 303-619-4711 Email: Bonnie@anewlifecenter.net	Call for your Free Hypnosis Assessment Consultation (to answer all your hypnosis questions) 303-619-4711

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Weight Loss - Mastery Questionnaire

Gain insight into your eating patterns by copying and completing this questionnaire, then call to schedule your FREE CONSULTATION appointment to discuss what you have discovered and how to overcome these sabotaging habits using hypnosis and hypnotherapy.

Name*
Company
Address*
Address2
City*
State*
Zip
Email*
Email Confirm*
Phone*
Fax
Do you Do you use food for any of the following reasons (check all that apply):	To numb feelings As a substitute for love As a substitute for attention For protection Out of Boredom Out of loneliness
Are you a binge eater
Do you eat when you are stressed
Do you eat when you are tired
Do you eat when you are nervous or anxious
Do you eat when angry
When did weight gain begin (at what age)
What was going on in your life at that time:
Were you "labeled" heavy as a child
Was there name calling involved
Were there large meals during childhood
Was there enough to eat in the home as a child
When do you eat: (check those that apply)	Only at meal times Between meals Get up at night to eat Eat all the time
What do you generally eat: (comfort foods such as mac & cheese, mashed potatoes, oatmeal or energy foods high in sugar/ fast foods/ healthy natural foods):
What type of exercise do you get:
How often:
Was there a time when you felt good about your body and felt fit?
If yes, when:
What are you not doing now because of your weight:
Can you picture yourself fit and healthy in the future?

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