Austin Hypnotherapy Solutions Weight Release Assessment Weight Release AssessmentFirst NameLast NameEmailDate / Time How long have you struggled with your weight? 1-5 years 5-10 years 10-20 years As long as I can rememberWhat are the biggest problem areas for you? (You may circle more than one) Poor food choices Bingeing Eating between meals Lack of exercise Lack of consistency with healthy behaviorsWhat factors affect your weight? (You may circle more than one) No willpower Easily influenced Fearful of being thin Can’t stick to a healthy regimen Lack of self-worth Emotional StateAre your parents and/or other family members overweight? Parent(s) Siblings Extended family All of the above None of the aboveDo you experience strong cravings for the following? (You may circle more than one) Sweets Chocolate Salty foods Starches I don’t have cravingsBriefly describe a typical day in your life with special attention to what and when you eat.How many times have you tried to lose weight and then gained it all back?What is the longest amount of time you were able to maintain a significant weight loss?Please describe what happened the last time you committed to a diet or weight loss program. How long did you stay involved with it?In hindsight, what caused you to begin deviating from this program?What type of plan has typically worked best for you in the past? (You may circle more than one) Keeping a food log Following a strict diet Exercising a lot Understanding the basic principles of a nutritional plan and following them Using my own best judgment and working out my own food plan OtherPlease describeThe ideal amount of assistance you believe you need: Very little involvement, I can do this on my own for the most part Lots of assistance and attention, I often hit roadblocks and need support to get me back on track A moderate amount of assistance, I’m able to maintain my behaviors for the most part, but need some help from time to time when things get toughTo achieve good long-term outcome what do you need? (You may circle more than one) Education about nutrition and exercise Someone to keep me responsible by checking up on me each week To learn how to become independent of external control I would like a minimum of involvement from othersWhat does good long-term outcome mean to you? What will be the conditions that would cause you to conclude that you have met your goal? How will your life be different? ) What is your ideal weight? When were you last at this weight? Do you have a picture of yourself at this weight?Submit Form
