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 didn’t 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