ALL INFORMATION IS STRICTLY CONFIDENTIAL. DATE: Name: Phone: Email address: Street address: City: State: Zip: Date of birth: Sex: Male Female Marital status: Single Married Divorced Widow Number of children Occupation: Education: Your medical history (allergies/surgery/addictions/diseases): May we notify your doctor of your desire to use hypnosis? What are your reasons for the appointment? Please list your reasons in order of importance: Have you ever been hypnotized before? If yes, under what circumstances? Do you have any fears concerning hypnosis? If so, please list them in order of importance: Do you know anyone who has derived benefits from hypnosis? (Please explain): How did you hear of Inessa Zaleski?