THE PATHWAY HYPNOTHERAPY ROOMSWeight Release Questionnaire Your responses to the following questions will enable me to construct and effective programme to help you to release the weight that you want. All information is private and confidential. Name Email Address Phone 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? For example, guilt, comfort, punishment, contentment, etc. On an average day, what do you eat and how much? a) For breakfast b) Mid-morning c) Lunch d) Mid-afternoon e) Evening meal f) Supper g) Other Do you snack between meals? If so, which, and what do you snack on? Do you ever get up during the night for something to eat? 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? If so, how many? Do you drink alcohol? If so, how many units per day Do you drink alcohol? If so, how many units 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 regularly finish off other people's food? Do you enjoy: (please tick where appropriate)?Sweet foods?Savoury 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? (Please tick)Stop over-eatingStop snacking between mealsStop drinking alcoholStop drinking sweet drinksStop eating junk foodsTake more exerciseHave more energy What suggestions do you feel would be most effective for helping you to achieve your goal weight? (Other) Are, or were, either of your parents, brothers or sister’s overweight? If so, please say which. Do you remember any instances of being 'forced' to eat up when you were younger?YesNo Was food ever used as a reward for doing something good?YesNo Did you ever eat to forget about something else?YesNo Did you often feel hungry as a child?YesNo Do you ever eat when you are not hungry?YesNo If yes, please give an example Do you ever eat to please someone else?YesNo If yes, please give an example Are you constantly thinking about the next meal?YesNo Do you have any problematic relationships in your life at present?YesNo 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? Exercise Do you lead an active life?YesNo Does your job involve sitting down a lot?YesNo Are you involved in any sport or regular exercise?YesNo If the answer to the above question is no, can you identify a sport that you would enjoy doing? 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?YesNo If yes, are you aware of any side effects from these that could cause weight gainYesNo If yes, are you willing to consult with your GP to find a more suitable alternativeYesNo Date Signature