Stop Smoking Questionnaire How did you hear about us? (please check ALL that apply)
Are you currently under the care of a physician?
Did your doctor recommend that you stop smoking?
Have you ever been diagnosed with epilepsy?
Are you currently overweight?
How much do you spend on cigarettes...
Have you figured out how much money you will save being smoke free for one year?
Are you embarrassed by your smoking habit?
Does your excessive smoking limit you and your activities?
Do you smoke more under stress?
Do you suffer from uncontrollable cravings?
Do you feel smoking controls you?
Does your smoking problem make you physically uncomfortable?
Has being a smoker caused you pain or suffering?
Do you believe stopping smoking has to be painful?
Do you smoke because of emotions?
Do you smoke after meals?
Is being smoke free top priority?
Does being a smoker limit your social life?
Do you feel tired, run down and out of energy?
Did you know that hypnosis is 100% safe?
Have you ever been hypnotized before?
Do you believe stopping smoking can be fun and enjoyable?
Does your family support your efforts to kick your habit?
Is your family excited about your using hypnosis to end your habit?
Can your remember being smoke free?
What is the most important element in deciding to use our services?
SUBMIT
