Stop Smoking Questionnaire
 
 
Instructions
Please fill out the form below, and click the SUBMIT button at the bottom of the screen to send your questionnaire to Anne Milligan's confidential e-mail.



Your Name: *
E-mail address and phone number/s.:*
How long have you been smoking?: *
Why did you start smoking?
Did someone you looked up to smoke?:
*
Have you tried to stop smoking in the past? What method did you use to stop smoking and what happened?:*
How many cigarettes do you smoke a day?: *
How much do you pay for a pack of cigarettes? How could you better use the money saved by being a non-smoker?:*
List the three main reasons why you want to stop smoking.:
What fears might you have for quitting smoking?:
Are you currently experiencing any medical problems related to smoking cigarettes? Please specify what they are if so.:*
When, where, and under what circumstances do you find yourself craving cigarettes the most? :
Are you currently under the care of a medical doctor? If so, please specify what you are being treated for.:*
Have you ever been hypnotized before? Please describe your experience/s. :





Confidentiality Consent to use E-mail

Please note that by pressing the "Submit" button below you are giving Anne Milligan authorization to communicate with you by e-mail.



(Fields marked with * are required)



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