Hypnotherapy Intake Form
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1Hypnotherapy Intake Form
Patient Information
Patient Name:
DOB:
Sex:
Home Phone:
Cell:
Address:
Medical History
Are you currently under a physician’s care?
Yes
No
Provider:
Do you currently see a therapist?
Yes
No
Therapist:
Treatments:
Effective?
Current Medications:
Current Stressors:
How well do you sleep?
How many hours per night?
Do you get angry often?
What angers you most?
Do you worry often?
What worries you most?
Are you happy?
What makes you happiest?
Are you pregnant?
Yes
No
Trying?
Yes
No
Breastfeeding?
Yes
No
Do you have epilepsy?
High/low blood pressure?
Diabetes?
Exercise Activities:
Hours per week:
Hypnotherapy
Reason for Visit:
What do you expect from hypnotherapy?
Have you experienced hypnotherapy before?
If yes, what were the results?
How did you hear about us?
If referred, who referred you?
Questions:
Comments:
Patient
Date
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Parent category: Business