Quit Smoking Form | Life in Sync – Hypnotherapy & Healing for Women

Quit Smoking Form

Session Date / Time

First Name

Last Name

Age

Birthday

Place of Birth

Address

City

State

Country

Mobile Phone

Occupation

Marital Status

Religion:

No of Children. Ages/Gender

What hobbies or enjoyable pastimes do you have?

What are you passionate about?

Doctor

Address

Phone

Did your doctor recommend you stop smoking?

Yes

Current Medications & how long been taking

Do you currently take nutritional supplements? If so, please list

Are you interested in health, vitality & wellbeing? 1 (not at all) 10 (very much) please indicate

Do you exercise? If so, what type and how many times a week?

Do you suffer with any of the following conditions? If so, please place X next to appropriate ones.

Conditions details/explanations

Have you ever been diagnosed with Dissociative Identity Disorder, Psychosis, Schizophrenia, Epilepsy?

Please list other therapies you have experienced (i.e. alternative healing, massage chiropractor, etc)

Have you experienced hypnosis?

Yes

Performed by

Purpose

Do you take recreational drugs? If so, what & how often.

Do you have any dietary/eating problems?

Do you drink alcohol? If so, what and how much/how often?

Have you ever done yoga/meditation?

Yes

Have you ever been in counselling?

Yes

What are the reasons that you have not been successful in quitting cigarettes up until now?

What does smoking do for you?

What specific reasons are you coming to quit cigarettes?

What other methods have you used to stop smoking?

How many cigarettes / packs do you smoke a day?

How much does this cost you per year?

How old were you when you started using cigarettes?

Why did you start?

When do you use cigarettes – what are your triggers?

Is there anything that is going to stop you from giving up smoking?

What is ONE thing you want to do instead of smoking that if you did on a regular basis would make a tremendous positive difference to your life?

Who referred you, or how did you hear about this service?

Any other relevant information

To the best of my knowledge this information is true and correct. I understand that all information I have provided will be held in the strictest confidence. I request hypnotherapy if deemed appropriate.