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Home
BWRT®
Services
Let go of your stress hypnosis
Quit Smoking Hypnosis
Stop Smoking Assurance Deal
Hypnosis to lose weight
Hypnosis for Sleep Issues
Hypnosis for fears and phobias
Hypnosis for Fear of flying
Hypnosis to Improve Confidence
Rates & Packages
Forms
About
My Approach
Client Testimonials
Hypnosis FAQ
Free Download
Blog
Contact
Talk to Trisha! 360-885-1965
Focus With Hypnosis | Hypnosis to quit smoking form
22249
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Hypnosis to quit smoking form
Step
1
of
6
- Personal
0%
Date
*
MM slash DD slash YYYY
Personal
Name
*
First
Last
Email
*
Phone (Preferred)
*
Alternate Phone
What time zone are you in?
*
Gender Identity
Age
*
Date of Birth
*
MM slash DD slash YYYY
Relationship Status
*
Single
Married
Divorced
Widowed
Do you have Children?
*
Yes
No
Children
*
Name
Age
Gender Identity
Smoking History
How old were you when you started smoking?
*
Why did you start smoking?
*
How many cigarettes do you typically smoke per day?
*
How long have you smoked that many for?
*
Is that less or more then in the past
*
Less
More
About the same
Pattern of Smoking:
When do you smoke?
*
Describe a typical day:
How do you know when to smoke?
*
Describe any triggers, like is there a special feeling you get when you feel the need to smoke or whenever I get a phone call, etc.
What is typically the best cigarette of the day?
*
Which would be the most difficult one to give up:
I continue to smoke because:
*
I enjoy it
It helps me to relax
It helps to break up my working time
It is something I do when I am bored
It helps me to cope with stress
It is something I do with my friends or family
It stops me from putting on weight
It keeps me from getting smoking withdrawal symptoms
Choose all that apply
What are the things you don’t like about your smoking?
*
It is expensive.
It is bad for my health.
It makes my clothes smell.
It makes my breath smell.
It makes me less fit.
I don’t like feeling dependent on cigarettes.
It is bad for the health of people near me.
People around me disapprove of my smoking.
It is a bad example for children.
It is a nasty habit.
Choose all that apply
Select any of these that you have:
*
Shortness of breath
Cough
Wheeze
Circulation problems
Asthma
Chest pain
Heart attack
Bronchitis
Emphysema
Angina
Stroke
Diabetes
Select any of these that you are worried about getting in the future:
*
Heart disease
Stroke
Lung cancer
Bronchitis
Diabetes
Circulation problems
Stopping in the Past:
Have you ever stopped smoking?
*
Yes
No
How long did you stop and when?
*
What worked for you then?
*
What was it like when you stopped?
*
Why did you restart?
*
Have you tried other methods to quit?
*
Gum
Patches
Chantix or other prescriptions
Have not tried other methods to quit
What might make it difficult for you to stop smoking now?
*
I enjoy smoking too much.
I would be too anxious or stressed.
I can’t resist the craving for a cigarette.
I don’t think I have enough willpower.
I think I am too addicted to cigarettes.
My partner smokes.
I would miss smoking with friends.
I think I would put on weight.
I don’t really want to stop.
I would be bored.
I would miss smoking breaks at work.
Choose all that apply
Considerations About Not Stopping:
Are you stopping because you want to stop or is someone pressuring you?
*
List three main reasons in order of priority why you want to quite smoking:
*
Do you have any fears about stopping smoking?
*
When you stop smoking, how supportive or helpful do you think the following people will be?
Spouse/Partner
*
Very supportive
Somewhat supportive
Not very supportive
Doesn’t care either way
Family Members
*
Very supportive
Somewhat supportive
Not very supportive
Doesn’t care either way
Friends
*
Very supportive
Somewhat supportive
Not very supportive
Doesn’t care either way
Coworkers
*
Very supportive
Somewhat supportive
Not very supportive
Doesn’t care either way
Succeeding as a Non-Smoker
On a scale of 1 - 10, 10 being maximum how would you rate your stress?
*
Please enter a number from
1
to
10
.
Briefly describe the causes of stress:
*
How confident are you about succeeding as a non-smoker?
*
Very confident
Fairly confident
Not confident
How do you expect to feel when you stop smoking?
*
How motivated are you to stop smoking?
*
Rate your motivation from 1 to 10 (with 10 being the highest motivation).
Please enter a number from
1
to
10
.
What are some hobbies or interests you enjoy and would like to spend more time doing once you become a non-smoker?
*
I want the Stop Smoking Assurance Deal
