Assured Effects Hypnotherapy - Time for change ...

Clinical Hypnosis in Poole, Bournemouth, Dorset and London

Smoker's Questionnaire

Smoker's Questionnaire

  • Full Name*
  • Email Address*
    eg. John@email.com
  • Contact Number*
  • Age*
  • Date of birth
    dd/mm/yy
  • Gender
  • Home address
    Fulll address including post code
  • Are you in a relationship?
  • Does your partner know you are coming for therapy?
  • Do you have children?
  • Occupation
  • Occupational Stressors
    What is stressful about work (if anything)?
  • Why do you want to stop smoking and why now?
  • What do you smoke?
  • Number of cigarettes/ tobacco products a day
  • How old were you when you started smoking?
  • Why did you start?
  • If other please state reasons
  • What do you get from smoking?
  • If other please state reasons
  • When do you smoke?
  • If other please state when
  • What frightens you about smoking?
  • Do you know someone who died through smoking?
  • Do you know someone who is ill now through smoking?
  • Has your doctor mentioned your smoking to you?
  • Have you had any warning signs or symptoms?
  • If yes please state
  • Do you have any health problems?
  • How long do you want to live?
  • What will you be able to do as a non-smoker that you could not do before?
  • What will you do with the money you save?
    ie. buy a new car, go on holiday etc.
  • Do you really want to stop?
  • What's stopping you?
  • Security Code*

     

  •