HYPNOSIS 2000

SLEEP QUESTIONNAIRE

COPY THIS PAGE AND PASTE ON EMAIL AND FILL IN FORM. I WILL RETURN YOU EMAIL ASAP.

1) FULL NAME ______________________________________________

2) NAME YOU LIKE TO BE CALLED ______________________________________________

3) DO YOU SMOKE CIGARETTES ______________________________________________

4) PACKS PER DAY YOU SMOKE ______________________________________________

5)AGE ______________________________________________

6) DO YOU HAVE ANY MEDICAL PROBLEMS IF SO PLEASE LIST OR CONTACT ME FOR MORE CONFIDENTIAL ANSWER _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Write down how many hours a night do you presently sleep
. ______________________________________________

Write down any experience you have when trying to sleep, like nightmares, etc.
. ______________________________________________
. ______________________________________________
. ______________________________________________


WRITE DOWN ANY TRAUMATIC EXPERIENCE YOU RECENTLY HAD (MARRIAGE, BIRTHS, DEATHS OR SICKNESS, CHANGE IN EMPLOYMENT, ETC.)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________

RETURN TO INDEX