Personal History Questionnaire – Hypno-Elevate Hypnotherapy

Name

Age

Occupation

Date of Birth

By whom were you referred?

Who presently lives with you?

CLINICAL QUESTIONS

In your own words, what issue are you seeking help with through hypnosis? How long have you had this issue? If you were to use a metaphor to describe the issue, what would this metaphor be?

What is the history and development of this issue (from the beginning to present)?

What real life events, if any, were happening around the time this issue started that might have contributed to the development or aggravation of this issue?

If you were to summarize what the ideal solution would look like to you, what would the ideal solution look or feel like to you? What metaphor would you use to describe the ideal solution?

On the scale below, please estimate the level of severity of your issue:

Mildly upsetting

Moderately Severe

Very Severe

Totally Incapacitating

With whom have you previously consulted about your present problems?

Have you ever been diagnosed with a psychiatric illness in the past? If yes, please explain.

Are you currently on any medications? If yes, please list the medications and dosages below.

OCCUPATIONAL QUESTIONS

What sort of work do you do?

What sort of work have you done in the past?

Does your present work satisfy you? (If not, in what ways are you dissatisfied?)

What were your past ambitions?

What are your present ambitions?

Write down any of the following words that you feel apply to you:

worthless – useless – nobody – life is empty – inadequate – stupid – incompetent – naïve – can't do anything right – guilty – evil – morally wrong – horrible thoughts – hostile – full of hate – anxious – agitated – cowardly – unassertive – panicky – aggressive – ugly – deformed – unattractive – depressed – unloved – misunderstood – bored – restless – confused – unconfident – in conflict – full of regrets – worthwhile – sympathetic – intelligent – attractive – confident – considerate – assertive

Do you have any fears or phobias around heights or water? If yes, please explain.

Can you visualize? If I was to ask you to think about the white clouds in the blue sky, could you see that in your mind's eye?

How you experience your memories? See them? Hear them? Feel them? Just a knowing that they are there? (Include all that apply)

What is an exciting flavor you enjoy?

What is a relaxing sound for you?

Out of all the colors in the rainbow, which one is the most relaxing for you?

What is a powerful image that motivates you and gives you power to move forward?

Which one of these three words resonate the most with you? Calm, Relax, Peaceful.

Have you ever been hypnotized before?

Yes

OTHER AREAS OF YOUR LIFE

Present interests, hobbies, activities:

How is most of your free time occupied?

What is the last grade of school you completed?

What are you scholastic abilities? What are your strengths and weaknesses?

Were you ever bullied, severely bullied or severely teased?

Do you make friends easily? If so, do you also keep them?

List your five main fears in order of importance:

Write down any words that apply to you in this list:

headaches – financial problems – fainting – palpitations – dizziness – no appetite – bowel disturbances – stomach trouble – insomnia – nightmares – fatigue – alcoholism – feel tense – take sedatives – tremors – unable to relax – suicidal ideas – shy with people – depressed – feel panicky – take drugs – don't like weekends – sexual problems – can't make decisions – don't like vacations – can't make friends – over rambunctious – can't keep a job – disoriented – unable to have a good time – concentration difficulties – memory problems

FAMILY DATA

In what ways does your family work together or get along?

In what ways might your family disagree or have issues?

How is your relationship with your in-laws if you're married? (this includes brothers/sisters-in-law)

How many children do you have? Please list their age and sex, if applicable.

Do your children present any special problems, if applicable?

Give details of any previous marriages, if applicable.

Is your father living or deceased?

If deceased, what was your age at the time of his death?

What was the cause of his death?

If your father is alive, what is his current age?

Occupation?

Status of his health?

Is your mother living or deceased?

If deceased, what was your age at the time of her death?

What was the cause of her death?

If your mother is alive, what is her current age?

Occupation?

Status of her health?

As a child, how did your parents punish you?

Give me an impression of your home atmosphere (ie. the home in which you grew up). Mention the state of compatibility between your parents. Also mention the start of compatibility between the parents and the children.

Were you able to confide in your parents?

If you have a stepparent, what was your age when your parent remarried?

Please provide a description of your religious training.

If you were not brought up by your biological parents, who brought you up? During what years did this person act as a parent for you?

Has anyone (parents, relative, friends) ever interfered in your marriage, occupation, etc? Who was it and what did they do?

Who are the most important people in your life?

SELF-DESCRIPTION

I am

I feel

I think

I wish

I would like to get advice on how to deal with my life and with other people(required)

Some

A lot

I would like to have my therapist respond to me on a person-to-person basis(required)

Some

A lot

I would like to get better self-control(required)

Some

A lot

I would like to get clarity regarding which things I think and feel are real and which are things mostly in my mind(required)

Some

A lot

I would like to work out a particular problem that's been bothering me(required)

Some

A lot

I would like to get my therapist to say what he really thinks(required)

Some

A lot