HYPNOSIS 2000

DECREASE STRESS 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 _______________________________________________________________________________

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Write down three places where you feel stressed. They can be work, with company, people you do not know, etc.
1. ______________________________________________

2. ______________________________________________

3. ______________________________________________


Write down the time of day you feel most stressed and why if you know why.
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Write down how long you have been feeling this way
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WRITE DOWN ANY TRAUMATIC EXPERIENCE YOU RECENTLY HAD (MARRIAGE, BIRTHS, DEATHS OR SICKNESS, CHANGE IN EMPLOYMENT, ETC.)
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