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Confidential Stop Smoking Questionnaire
Your success is our #1 Priority. Help us to help you attain that success by filling out this questionnaire. The Questionnaire will become part of your file, it is important for us in the process of helping you become a non-smoker forever.
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Name:
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Address, City, State, Zip:
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Home Phone:
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Work:
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Mobile Phone:
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| Birthday: |
E-mail: |
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Are you Currently Taking any Pain Medication or Anti-Depressants?
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| How Many Cigarettes Do You Smoke a Day? |
What Brand? |
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| What Age Did You Start Smoking & Why: |
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What Methods (If Any) Have you Used to Try to Stop Smoking Before?
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Have You Ever Quit for More Than a Month? (List the Method Used)
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Why Did You Start Again? List Reasons for Starting Again
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| At IGHWA, we believe that when you agree to stop smoking, you are making a commitment to become a healthier individual. Remember every time you do something positive you are reminding yourself that you have control of your life. |
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| List 3 new healthy things you can do when you quit smoking, check from the below list or add your own plans to develop a new healthier you. |
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The Best Thing: a Brisk 20 Minute Walk Outside, Every Day, Rain or Shine!
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| On a Scale of 1-10 How Committed are you to Stopping Smoking Today: |
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Reasons to Quit Smoking
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| Below I have listed 12 common reasons people want to quit smoking. Pick out the 3-4 most popular or embarrassing reasons that cause you to realize that now is the time to quit smoking. You can also add your own. List below according to importance to you. If Health is your most important reason, list it first. I will empathize the reasons that are important to you during the hypnosis session. |
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1. Controlled By Cigarettes
2. Money or Expense
3. Children or Grandchildren
4. Health
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5. Coughs & Colds
6. Breathing
7. Inconvenience
8. Death & Dying |
9. Pressure from Others
10. Smell of Smoking
11. Antisocial
12. Premature Aging |
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Please Type Your Name as a Confirmation of Filling out this form.
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