The Therapy Place Lifestyle Questionnaire for Hypnosis


Name ____________________________                Date_______________

How much (approximately) do you weigh? ____________

What is your goal weight? _________

When in your life were you your ideal weight? _____________

What changed in your life when you began to gain weight? _____________________
_______________________________________________________________

What emotions do you associate with this period in your life?  i.e. Guilt, comfort, punishment, contentment, etc.
_____________________________________________________________________

On an average day, what do you eat and how much and what time of day?
a) For breakfast.........................................................................................................
b) Mid-morning ..........................................................................................................
c) Lunch ..................................................................................................................
d) Mid-afternoon .......................................................................................................
e) Evening meal .........................................................................................................
f) Supper .................................................................................................................
g) Other ..................................................................................................................


Do you snack between meals? YES   NO
If yes, what do you snack on?  _________________________________________

Do you ever get up during the night for something to eat ? YES        NO

If you overeat, which of the above foods would you like to cut down on, or cut out altogether?
___________________________________________________________________

Approximately how many drinks do you have a day? _______________

Do you drink fizzy or sweetened drinks?  YES      NO   If so, how many? _____

Do you drink alcohol?  YES   NO  If so, how many per week ___________

Do you drink water?  If so, how many glasses approximately per day? ______

Who does the food shopping in your household? _________________________

Who prepares and cooks the food? _____________________________________

Do you often leave food on your plate? __________________________________

Do you finish off other people's food? ___________________________________

Do you enjoy: (please check where appropriate)
Sweet foods?  ____
Salty foods?  ____
Fresh fruit?  _____
Fresh vegetables?   _____
Starchy foods?   _____
Fatty foods?    _____

What suggestions do you feel would be most effective for helping you to achieve your goal weight?
Stop overeating   ___
Stop snacking between meals  ____
Stop drinking alcohol  ___
Stop drinking sweet drinks  ___
Stop eating junk foods ___
Take more exercise  ____
Have more energy ____
Other ________________________________________________________________

Are, or were, either of your parents, brothers or sisters overweight?  If so, please say which.
_____________________________________________________________________

Do you remember any instances of being 'forced' to eat up when you were younger?  YES / NO

Was food ever used as a reward for doing something good? YES / NO

Did you ever eat to forget about something else? YES / NO

Did you often feel hungry as a child? YES / NO

Do you ever eat when you are not hungry?  YES / NO
If yes, please give an example ____________________________________________
_____________________________________________________________________

Do you ever eat to please someone else?  YES / NO
If yes, please give an example ____________________________________________
_____________________________________________________________________

Are you constantly thinking about the next meal?  YES / NO

Do you have any problematic relationships in your life at present YES / NO
If yes, please state with whom ____________________________________________
If you answered yes, how do you see this relationship improving _________________
_____________________________________________________________________

How many hours sleep (approximately) do you have per night? ________

Physical Activity
Do you lead an active life?   YES / NO

Does your job involve sitting down a lot?  YES / NO

Are you involved in any sport or regular exercise YES / NO
If the answer to the above question is no, can you identify a sport or physical activity that you would enjoy
doing? YES / NO
If yes, please say what this would be ______________________________________
When would a convenient time for you to do this, be? _________________________

Medication
Are you currently taking any drugs or prescribed medication?  YES / NO
If yes, are you aware of any side effects from these that could cause weight gain
YES / NO
If yes, are you willing to consult with your GP to find a more suitable alternative
YES / NO.    

What are some of the reasons you would like to shed pounds and adopt a healthy lifestyle?


What are some of the things that you  will be doing or trying for the fist time as a result of your healthful life?
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________

By signing below I pledge to adopt a lean and healthy lifestyle starting __/___/_____.


Signature__________________________________________

If you are filling out this questionnaire outside of the office you can mail to
The Therapy Place
Attn: Gretchen Laporta LCSW
Address
OR    Electronically send to GretchenLCSW@Yahoo.com