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Patient Forms
 
PATIENT HISTORY
Name
Address
Phone Number
Email address
Date of Birth
Age
Gender
Marital Status
# of children
Employed by
Title
How did you hear about us?
Have you ever been hypnotized
Yes
No
MEDICAL HISTORY
Have you been under a Dr.'s care in the past year?
Yes
No
If yes, please say the reason.
Dr.'s Name
Have you ever been treated for an emotional problem?
Yes
No
If yes, are you currently receiving treatment or counseling?
Yes
No
Have you had any prolonged illness?
Yes
No
If yes, when?
Reason
Have you ever been treated for
Heart
Diabetes
Epilepsy
Are you currently on any medication? If so, what?
Reason for medication
Reason you are coming for Hypnotherapy
Any previous efforts to solve the problem?
Yes
No
Results
Are you currently undergoing medical or psychological treatment for the above problem?
Yes
No
Where?
Dr.'s Name
Do you have any questions about Hypnotherapy?
Electronic Signature
If you wear HARD contact lenses, before your session, please remove them, as they inhibit your ability to relax.
Thank You!