Weight Loss Questionnaire

Date of 1st Consultation

Full Name *

Phone *

Email Address *

Address *

City *

State *

Zipcode *

Date of Birth *

Gender * MaleFemale

How did you hear about us? *

Why is it that you want to lose weight? *

What attempts at weight loss have you made previously?

Lets say its a year from now, what are your weight loss goals?

Has there been a time where everything was in line in terms of your health? When was that time for you?

Lets say its a year from now you have that weight off your body - what do u see being different now because of that change?

Have you ever been hypnotised before? If so what was your experience like?

Are you currently taking any medications? Medical conditions? (seizures, epilepsy, etc.?)

Are their particular situations or events you feel you have less control over eating food?

Is there anything else would like to add before we start our sessions?

Mental Coach Signature *

Client Signature *

Notes
***. The trainer is neither a medical doctor nor a psychologist and does not treat nor diagnose medical or psychological conditions. Progress reports may be sent to the attending doctor. Any persons who is currently working with a licensed professional (therapist, psychologist, MD, social worker) must get a written referral.
* Sessions may be recorded for educational purposes

Weight Loss

Based on a clinical trial where 95% of Participants lost weight. The Virtual Gastric Band is a personalised program in which you change the way you relate to food to something far more positive.

The Virtual Gastric band is a non-surgical procedure where using the power of the subconscious through hypnosis, to convince the mind that it is full after eating the appropriate amount of food.

This is Not a Diet , this procedure allows you to eat what you want while being satisfied with smaller portions of food during the day.

This is your long-term solution to your weight loss challenge.

Weight Loss

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