Stop Smoking QuestionnaireStop Smoking Questionnaire Name Name First First Last Last Date Address Home Phone Work Phone Email Date of Birth Age Gender MaleFemaleNonbinary Marital Status Single Married Widowed Divorced Height Weight Text Favorite Hobby Occupation How did you hear about us? WatermarkColumbia.com Web SearchWeb Search GoodTherapy.org Facebook/TwitterFacebook/Twitter Referral (name)Referral (name) PsychologyToday.com Radio (station)Radio (station) OtherOther Next Are you currently under the care of a physician? Yes NoDid your doctor recommend that you use hypnosis? Yes No Physician's Name Have you ever been diagnosed with epilepsy or had seizures of any kind? Yes NoDo you exercise? Yes No How often? Do you feel stress? Yes No Explain What worries you most? What do you want from hypnosis? What do you expect from hypnosis? Did you know that hypnosis is 100% safe? Yes NoHave you ever been hypnotized before? Yes No Results Why did you choose us for hypnosis? How long have you been smoking? What is the longest period of time you have been smoke free? Are you currently overweight? Yes No If so, by how much? How much do you spend on cigarettes? Day $Day $ Week $Week $ Month $Month $Have you ever figured how much money you will save by being smoke free for one year? Yes No If so, how much? If not, why not? How many packs a day do you smoke? Are you embarrassed by your smoking habit? Yes NoDoes your excessive smoking limit you or your activities? Yes NoDo you smoke under stress? Yes NoDo you suffer from uncontrollable cravings? Yes No Explain Do you feel smoking controls you? Yes No How many times have you failed at quitting smoking? What methods have failed to help you stop smoking? Does your smoking problem make you physically uncomfortable? Yes NoDo you smoke because of emotions? Yes NoDo you smoke after meals? Yes NoIs being smoke free a top priority? Yes No What do you think is the most difficult part about stopping smoking? Do you believe stopping smoking has to be painful? Yes No Briefly describe your smoking behavior Do you believe stopping smoking can be fun and enjoyable? Yes No How soon do you want to be smoke free? Does your family support your efforts to kick your habit? Yes NoIs your family excited about your using hypnosis to end your habit? Yes NoDoes being a smoker limit your social life? Yes NoDo you feel tired, run down and out of energy? Yes NoCan you remember being smoke free? Yes No When What do you remember about being smoke free? Has being a smoker caused you pain or suffering (physical or emotional pain)? Yes No Explain What is the most important element in deciding to use our services? Effectiveness: "My results are my top priority" Time: "I want results quickly" Service: "I need extra support along the way" Affordable: "What you charge is my concern" Date Please choose yes or no for the following questionsI use tobacco in larger amounts or over longer periods of time than I intended. Yes NoI have had a persistent desire to reduce or control my use of tobacco, or I have been unsuccessful in doing so. Yes NoI spend a great deal of time on activities necessary to obtain or use tobacco. Yes NoI have a craving, or a strong desire or urge to use tobacco. Yes NoMy use of tobacco interferes with my work (or major obligations at home or in school). Yes NoI have continued to use tobacco even though it leads to persistent or recurring social or interpersonal problems (such as arguments with others about tobacco use, or feeling ostracized). Yes NoI have given up important social, work-related, or recreational activities because of my tobacco use. Yes NoI continue to use tobacco in situations where it is physically hazardous (such as smoking in bed). Yes NoI continue to use tobacco in spite of the fact that I know I have a persistent or recurring medical, physical, or psychological problem which is made worse by my use of it. Yes NoI notice I need more tobacco to have the same effect, or I am finding the same amount of tobacco does not have the same effect on me. Yes NoI have irritability, frustration, anger, or anxiety when I try to quit using tobacco, or I have to use a nicotine patch or gum (or similar product) to alleviate those symptoms. Yes No Section Buttons If you are human, leave this field blank. Submit
