ARE YOU READY TO STOP SMOKING? (CONFIDENTIAL)
Answer the questions below and we'll let you know!
*Mandatory field

1. *Email address:
2. *Forename:
3. *Surname:
4. Known as:
5. *Post code:
6. Contact telephone number
(incl. STD code): [PREFERRED]
7. *Age:
8. Sex:
9. *Is your work stressful?
10. *Are you currently taking any medication?

11.
If you answered "yes" to the above question, please list any medication you are currently taking here:

12.
*From which of the following health problems do you suffer, if any (please check any or all that apply)?
None
Heart Problems High Blood Pressure
Epilepsy Diabetes
Asthma Ulcers

Other(s) (please specify in the space below):

13.
*Are you currently under the care of a doctor?

14.
*Did your doctor recommend that you stop smoking?

15.
*Do others in your family or circle of friends smoke?

16.
If you answered "Yes" to the above question, what is the relationship you have?

17.
*Does other people smoking worry you in any way?

18.
If you answered "Yes" to the above question, does other people smoking worry you with regards to stopping smoking?

19.
*What is the lowest number of cigarettes you smoke a day?
20. *What is the highest number of cigarettes you smoke a day?
21. *What age did you start smoking?

22.
Why did you start smoking (please tick any / all that apply)?
Peer pressure To rebel against authority
To appear more adult It was the done thing

Other(s) (please specify in the space below):

23.
What do you get from smoking and what does it do for you (please tick any / all that apply)?
Relaxes me Helps me concentrate
Excuse for a break Confidence boost
A prop Helps relieve boredom
Comfort I enjoy smoking
Don't know  

Other(s) (please specify in the space below):

24.
What other methods (if any) have you used to try to stop smoking in the past (please tick any / all that apply)?
None  
NRT (Patches / Gum / Inhalers) Zyban
Willpower Hypnosis
Books Courses
Acupuncture  

Other(s) (please specify in the space below):

25.
*What are the reasons that YOU want to stop smoking and why now? Please be as specific as you can - bear in mind there are no right or wrong answers.

26.
If you have had had any worrying symptoms that may be related to your smoking, please give details here:

27.
*What will you be able to do / gain / experience / have as a non-smoker, that you couldn't before?

28.
*How did you hear about the Advanced Hypnotherapy Centre?

29.
If you selected "Other" in response to the above question, please specify here:

30.
If we were recommended to you, please enter the name of the person who recommended us:

31.
*Do you really want to stop smoking?

32.
What has stopped you from giving up smoking in the past?

33.
If you would like a free telephone consultation, please enter your contact telephone number(s) and preferred time(s) here:

34.
If you have any concerns about hypnosis and / or stopping smoking, please enter them here:

35.
Please tick any other services you might be interested in:
Easy weight loss Phobias
Confidence Compulsions
Addictions Letting go of negative emotions
Eliminating bad habits Panic attacks
Corporate packages  

Other(s) (please specify in the space below):
   

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Telephone: 0208 241 3000

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