Health Questionnaire

Original Date:	when you have completed this form, CLICK FILE SEND PAGE BY EMAIL
	to welterk@shaw.ca or hnichols@shaw.ca we will respond to your enquiry within 24 hours.
Assessment for Hypnotherapy & NLP Hypnotherapy & NLP in Canada www.hypnotherapy-nlp-canada.com www.waysofthewisewoman.com www.justbewell.com
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Name (Last, First, M.I.)			¨

Have you ever been hypnotised? ¨ Yes ¨ No Date last hypnotised: Have you ever had a NLP Session? ¨ Yes ¨ No Date: Was your session helpful ¨ Yes ¨ No - any additional comments? What worked for you, what didn’t?
Please list your goals for NLP/Hypnotherapy: What is the single most important goal you want to achieve out of your sessions? If you could have your dream, what would it look like? What would your dream feel like? What would it sound like?




Have you ever had any other serious accidents, injuries or illnesses? Please include surgeries or hospitalizations






List any prescribed drugs, over-the-counter drugs, vitamins, remedies or inhalers that you are using.
Name of Product		Strength		Frequency Taken and Reason Prescribed

General wellness
Assisting me to understand your current emotional and mental state can help considerably with your treatment. Please consider answering the following questions:
Is stress a major problem for you?	¨	Yes	¨	No
Do you feel depressed?	¨	Yes	¨	No
Do you have anxiety or panic when stressed?	¨	Yes	¨	No
Do you have problems with eating or your appetite?	¨	Yes	¨	No
Do you have trouble sleeping?	¨	Yes	¨	No
Have you ever been to a counselor? For what purposes?	¨	Yes	¨	No

Was the counseling of assistance to you?	¨	Yes	¨	No

Would you like to share any other information that you feel is relevant to your treatment?

Thank you for sharing this information. This information will assist the practitioner to tailor your treatment appropriately.

Appointment Date Preference:

Location Preference: Burnaby Yaletown

Original Date: