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INSTRUCTIONS: This brief questionnaire will help you determine how successful you can be in learning self-hypnosis to improve how you feel, manage pain better, and change your self-defeating behavior. There are 10 questions.

Answer each question Yes or No. To calculate your total score on this questionnaire, give yourself 10 points for each Yes answer and 0 points for each No answer. The highest score you can get is 100. Any score over 50 means that you can be successful in learning to use self-hypnosis!

1. Do you ever daydream pleasant things on purpose?  Yes No
2. Do you ever believe your pleasant daydreams?  Yes No
3. Have you ever become really absorbed in watching a TV program, or movie, or listening to a story, or piece of music, or reading a book?  Yes No
4. Have you ever changed the way you felt about something?  Yes No
5. Do you ever enjoy falling asleep in your bed or easy chair when you are tired?  Yes No
6. Have you ever enjoyed taking a mid-day nap?  Yes No
7. Have you ever learned that you knew something you didnít think you knew?  Yes No
8. Have you ever used your thinking abilities to help yourself?  Yes No
9. Have you ever worked on learning how to control your own mind?  Yes No
10. Do you ever imagine or daydream things you like to help you feel better?  Yes No



 

 
     
 

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