Online Stop Smoking Form - Free suitability results email



	Thank you for enquiring about stopping smoking This online stop smoking form is an aid to stopping smoking and saves time at your session. Please answer the questions below honestly as they will help me to predict your suitability for the process and increase the success rate for you giving up your smoking habit. All information requested is used only in your assessment and treatment. No information is used by or sold to a third party for any reason. All communication is confidential and private. or just contact me via my email or mobile 07940029383 to arrange a free initial consultation email address : info@openpalm-hypnotherapy.com Please add your name Online Stop Smoking Assessment form Please answer the questions honestly This should only take a few minutes to complete Please add your full name Please add your email address Please add your contact number Preferred method of contact Phone Email About you Your Date of Birth DD/MM/YYYY example - 10/01/1980 Sex Male Female Marital status Are you Single Married Long term relationship If you are in a relationship does your partner smoke ? Yes No occupation Smoking related questions How long have you smoked ? 5-10 years 10-15 years 15 years or more How many cigarettes / cigars do you smoke per day on average ? 5-10 10-20 20-30 40 or more Have you tried stopping smoking before ? Yes No If yes please give details of how you tried before More about you How do you sleep? Well Restlessly Badly Hardly at all Do you have a stressful job / Life ? Yes very Quite Non stressful Retired Do you grind your teeth ? Yes Sometimes No Do you suffer with back pain ? Yes No Do you suffer from headaches / migraines ? Yes No Have you or do you suffer from Depression ? Yes No Have you or do you suffer from Panic/anxiety attacks ? Yes No Do you lack self confidence ? Yes No Do you worry too much ? Yes No Do you experience recurring thoughts or behaviours ? Yes No Do you suffer from irrational fears or phobias ? Yes No Final questions Does smoking relax you ? Yes No Do you think in your personal opinion that smoking is Addictive Habit or a bit of both Any other information or comments please feel free to enter them in the comments box below. Thank you for your time please submit this form * Please note that all information on this form is confidential and will not be passed on to any third party.
	Matthew Smale Registered Hypnotherapist No. 81846 Privacy - copyright 2011 - weblinks