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HEALTH

HISTORY
QUESTIONNAIR
E
Original Date:
:
Suggestibility Results
%

%
All questions contained in
this questionnaire are strictl
con!idential and "ill #eco$e
%art o! our %ersonal
treat$ent record& This
in!or$ation cannot #e shared
"ithout our e'%ressed
consent&
The in!or$ation gathered
here is not !or $edical
%ur%oses( si$%l to get an
o)erall )ie" o! our health&
Name *Last+ ,irst+ -&I&.
Sune Naude - X ,
DOB:
DD /01 /2 -- YEAR
/345
Home Address
STREET
6ITY17RO8 A#u Dha#i UAE 7OSTAL
Phone 93:/
0; ;35 44<0
Ho$e:
=or>:
-o#ile:
6an "e lea)e
%ersonal
$essages on
%hone?
Yes
X No
Email
sune_naude@
hotmail!om
=hat is the
#est "a to
contact ou?
e$ail1 s>%e
"arital status
X Single
7artnered
-arried
Se%arated
Di)orced
=ido"ed
#ho re$erred
you%ho& did
you hear about
us'
8erster&&&
Ha(e you e(er
been
hy)noti*ed'
Yes X
No
Date last
hy)noti*ed:
Hy)nothera)is
t:
Reasons $or
hy)nosis:
Please list
your
+,RREN-
goals $or
hy)nothera)y:
( to !ind
#alance "ithin
$ li!e
( to !ind out
"hat it is I a$
$eant to do
( to succeed in
$ current
%osition
( to %ursue a
lo)ed one
( to #e ha%%+
not
de%ressed+
suicidal
7ERSONAL
HEALTH
HISTORY
Any )roblems
that other
health !are
)ra!titioners
.do!tors/
healers/ et!0
ha(e
diagnosed'
Ha(e you e(er
had any other
serious
a!!idents/
in1uries or
illnesses'
Please in!lude
surgeries or
hos)itali*ation
s
Year Details
2@//
7aracete$ol
o)erdose+
resulting n
se)ere li)er A
>idne !ailure
#hat other
traumas are
you a&are o$
e2)erien!ing
in your
li$etime'
Year Details
Nothing
s%eci!ic+ a lot o!
heart ache+
sadness
de%ression !or a
)er long "hile
Do you ha(e
any s)e!i$i!
$ears or
)hobias that
you are a&are
o$' .eg $lying/
heights/ &ater/
et!0 Please
in!lude any
re!urring bad
dreams
Issue Details
3ist any
)res!ribed
drugs/ o(er4
the4!ounter
drugs/
(itamins/
remedies or
inhalers that
you are using
Na$e o!
7roduct
Strength ,requenc
Ta>en and
Reason
7rescri#ed
Yas$in
dros%irenone
<&@@@$g
ethinlestradiol
@&@<@$g
dail+
contrase%ti)e
6ran#err
dietar
su%%le$ent
<;@@$g
dail+ )ita$in 6
inta>e
Blucosa$ine A
6hondroitin
7LUS
/0@@$g
A/2@@$g
dail+ Coint %ains
6entru$ $ulti(
)ita$in
dail+ $ulti
)ita$in
Al!ohol%Drugs Are ou
concerned
a#out the
a$ount ou
drin>?
Yes X No
Are ou
concerned
a#out drug use+
%har$aceutical
or street?
Yes X No
=ould ou li>e
to discuss
alcohol or drug
use during our
treat$ent?
Yes X No
-oba!!o Do ou use
to#acco?
X Yes No
X 6igarettes D
/15 %>s&1da
6he" (
E1da
7i%e ( E1da
6igars (
E1da
/12 o! ears
Or ear sto%%ed
s$o>ing
=ould ou li>e
to discuss
to#acco use
during our
treat$ent?
X Yes X No
Personal
Safety
Physical
and/or
mental abuse
has become
a major
public health
issue. This
often takes
the form of
verbally
threatening
behavior or
X Yes No
actual
physical or
sexual
abuse.
Would you
like to
discuss this
issue with
your
practitioner
Are there any
other )ersonal
sa$ety
!on!erns you
&ish to
highlight' 5$
so/ )lease
des!ribe
belo&
X Yes No
suicidal
thoughts1
notions
BENERAL
=ELLNESS
Assisting me to
understand your
!urrent emotional
and mental state
!an hel)
!onsiderably &ith
your treatment
Please !onsider
ans&ering the
$ollo&ing
6uestions:
Is stress a $aCor
%ro#le$ !or ou?
X Yes No
Do ou !eel
de%ressed?
X Yes No
Do ou ha)e
an'iet or %anic
"hen stressed?
Yes X No
Do ou ha)e
%ro#le$s "ith
eating or our
a%%etite?
X Yes No
Do ou ha)e
trou#le slee%ing?
X Yes No
Ha)e ou e)er
#een to a
counselor? I! es+
%lease descri#e&
Yes X No
=as the Yes No
counseling o!
assistance to ou?
=O-EN
Are ou %regnant? n1a
=ould ou li>e in!or$ation a#out H%nosis !or Firth? n1a
OTHER
6HE6G I, YOU HA8E+ OR HA8E HAD+ ANY SY-7TO-S IN THE ,OLLO=INB AREAS TO A
SIBNI,I6ANT DEBREE AND FRIE,LY EH7LAIN&
S>in6hest1HeartRe!ent !hanges in:
Head1Nec> Fac> =eight
EarsIntestinalEnerg le)elX
Nose Fladder X A#ilit to slee%
ThroatFo"elOther %ain1disco$!ort:LungsX6irculation#ould you li7e to share any other in$ormation
that you $eel is rele(ant to your treatment'
All due to "or>( s%ending long hours on $ !eet+ constantl "or>ing di!!erent shi!ts and hours
Thank you for sharing this information. This information will assist the practitioner to tailor your treatment
appropriately. By signing this health record you agree that you have provided this information voluntarily and
are undertaking hypnotherapy with this office voluntarily. You agree to release this practitioner from all liability
and will not hold the practitioner responsible in any way for outcomes resulting from methods, instructions and
programs used in the course of your treatment.
Signed Date
Pra!titioner Notes: