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HYPNOTHERAPY ASSESSMENT FORM

ESA HOLISTIC NURSING CENTER CENTER


Jl Tengger Barat III / 4 Semarang
Please complete this form at initial session. Note : All Information is STRICTLY CONFIDENTIAL
Todays date : _____________________
Name

: ___________________________________________________________________________

Adress : ___________________________________________________________________________
City

: __________________

State : _______________

Zip

: _________________

Date of Birth : ____/____/_______ Male__ Female __ Single__ Married__Separated__Divorced_____


Home phone : __________________ Work Phone : _________________Hp : ____________________
Occupation : ________________________
Nationality : ________________________ Daily language : _________________________
Have you ever been hypnotized ? YES __ NO __ If yes, describe when, where, why, by whom ? _____
____________________________________________________________________________________
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Have you ever walked in your sleep ? Yes __ No __ Talked in your sleep ? Yes __ No __

MEDICAL HISTORY
Have you ever been under treatment ( physical or psychological) in the past year ? Yes__No__
If Yes, describe _______________________________________________________________________
____________________________________________________________________________________
Name of physician : ____________________________________ Phone : ________________________
Have you ever been treated for an emotional problem ? Yes__No__
If Yes, are you currently receiving treatment or counceling ? Yes__No__
Have you had any prolonged illness ? Yes__No__ If yes, when _________________________________
_____________________________________________________________________________________
Have you ever been treated for ? Diabetes__Epiplepsy__Heart Desease__ other :____________________
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If yes, when : __________________________
Nature of presebt problem (reason you wish hypnotherapy treatment ) : ____________________________
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Any previous efforts to solve this problem ? Yes__No__ Results ? _______________________________
______________________________________________________________________________________
Are you currently undergoing medical or psychological treatment for above problem ? Yes__No__
Name of physician/therapist : ___________________________ Phone : ____________________________

HYPNOTHERAPY ASSESSMENT FORM

Are you presently on any medication ? Yes__No__ If yes, describe : _______________________________


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SPECIAL NOTE :
Note what you like and dislike :
Friend : _____________________________________________________________________________
Colour : _____________________________________________________________________________
Place

: ________________________________

Famous people you interest : __________________________________


Hobbies : __________________________________________________
Food

: ______________________________________________________________________________

Pet

: ______________________________________________________________________________

Situation

: _______________________________________________________________________

Occupation : __________________________________________________________________________

Describe, what you want from this session of hypnotherapy : _____________________________________


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Note other information :
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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Client

Hypnotherapist

_______________
____________________
By Signing this form, you acknowledge that you understand this questionnaire, and all information provided is
complete and accurate to the best of your knowledge