ARE YOU READY TO LOSE WEIGHT? (CONFIDENTIAL)
Answer the questions below and we'll let you know!
*Mandatory field

1. *Email address:
2. *Forename:
3. *Surname:
4. Known as:
5. *Post code:
6. Contact telephone number
(incl. STD code): [PREFERRED]
7. *Age:
8. Sex:
9. *Is your work stressful?
10. *Are you currently taking any medication?

11.
If you answered "yes" to the above question, please list any medication you are currently taking here:

12.
*From which of the following health problems do you suffer, if any (please check any or all that apply)?
None
Heart Problems High Blood Pressure
Epilepsy Diabetes
Asthma Ulcers

Other(s) (please specify in the space below):

13.
*Are you currently under the care of a doctor?

14.
*Did your doctor recommend that you lose weight?

15.
*What is your current weight?
st lbs
16. *What is your target weight? st lbs
17. *What is your height? ft ins
18. *What age did you start being overweight?

19.
*What methods / diets have you used to try to control your weight in the past? If you have not tried anything before, please type "None".

20.
What are the reasons that contribute towards you being overweight (please tick any / all that apply)?
Comfort Boredom
Always been this way Like feeling full
Deserve it Time
To relax Family eating habits
Like sweet things Slow metabolism
Eat out / takeaways a lot Socialise a lot
Cannot help myself Eat too much at mealtimes
Eat between meals Lazy
No exercise Don't realise how much I eat until afterwards
At the time it doesn't matter Don't know
   

Other(s) (please specify in the space below):

21.
Which particular times of the day or events do you feel contribute to this problem?

22.
Which specific types of food or drink do you find it difficult to control?

23.
*What are the reasons that YOU want to take control of your weight and why now? Please be as specific as you can - bear in mind there are no right or wrong answers.

24.
*How did you hear about the Advanced Hypnotherapy Centre?

25.
If you selected "Other" in response to the above question, please specify here:

26.
If we were recommended to you, please enter the name of the person who recommended us:

27.
What has stopped you from losing weight or keeping the weight off in the past?

28.
If you would like a free telephone consultation, please enter your contact telephone number(s) and preferred time(s) here:

29.
If you have any concerns about hypnosis and / or taking control of your weight, please enter them here:

30.
Please tick any other services you might be interested in:
Stopping smoking Phobias
Confidence Compulsions
Addictions Letting go of negative emotions
Eliminating bad habits Panic attacks
Corporate packages  

Other(s) (please specify in the space below):
   

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Telephone: 0208 241 3000

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