Hypnosis Institute of Texas, Inc.
2. Have you ever seen anyone hypnotized? ______________ Y ________N
3. Do you believe hypnosis can help you w/your problem? __Y___ _____N
4. Have you ever walked or talked in your sleep? _____ ____Y ________N
5. Have you ever awakened in the middle of your sleep state and felt like you couldn't move or speak? _____________________________Y ________N
6. Are you basically a trusting person? __________________Y ________N
7. Do you have a vivid imagination? _____ ______________Y ________N
8. Do you day dream or involve yourself in fantasy? _______Y _______N
9. Are you able to concentrate on an idea or thought? ______Y _______N
10. Do you feel comfortable being touched by someone you trust? __Y _N
11. Are you open to new ideas? _____________________________ Y _N
12. Are you able to follow directions or instructions? ____________Y __N
13. Are you able to get in touch with your emotions easily? _______Y __N
14. Do you believe it's possible for a person to be healed by the power of his/her mind? _____ ____________________________________________Y __N
15. Have you ever wished you avoid taking medication? _________Y ___N
16. Do you enjoy reading fiction and get involved in the story? ____Y ___N
17. Are you basically a religious or spiritual person? _____________Y ___N
18. Do you find talking about the supernatural fascinating? _______Y____N
19. Have you ever meditated? _____ ________________________Y ___N
20. Are you able to sit or lie still for a period of time? _____ _____Y ___N
21. If you were to imagine sucking on a sour, bitter, juicy, yellow lemon, would your mouth begin to water? _____ _________________________Y ___N