Quit Smoking Questionnaire

Your Name (required)

Your Email (required)

How many cigarettes do you usually smoke in a day?Between 1 and 10Between 11 and 20Between 21 and 30Between 31 and 40More than 40

Do any others in your family smoke?YesNo
If YES then who?

At what age did you start smoking?

Why did you start?

What do you get from smoking?

Is your work/life stressful? YesNo
How stressful?

Have you experienced hypnosis before?YesNo
If YES then when and what was that for?

Have you ever seen a psychologist, psychiatrist or counsellor before?YesNo
If YES then when and what was that for?

Are you taking an antidepressant? YesNo
If YES what are you taking?

Do you have any general health issues?
Fears or Phobias YesNo
Heart YesNo
Blood Pressure YesNo
Diabetes YesNo
Asthma or difficulty breathing YesNo
Other YesNo

If OTHER and/or you have a FEAR or PHOBIA please briefly describe these here

Do you smoke marijuana or take drugs? YesNo
If YES how often and what are you taking?

Do you drink alcohol?YesNo
If YES how many drinks in a week and what do you drink?

Have you tried to stop using patches or gum?YesNo
If YES what have you tried?

What frightens you about smoking?

Do you know anyone who has died or been seriously unwell as a result of smoke or smoking?YesNo
If YES who?

What is motivating you to quit?

Who are you important to and why?

Have you experienced any worrying symptoms which might be related to your smoking? YesNo
If YES then what symptoms?

Who is responsible for your health?

What will you be able to do as a non-smoker that you could not do before?

What will you do with the money that you save?

Do you really want to stop smoking?

What is stopping you?

How quickly do you want to give up?

What are your most important reasons to Quit?
To regain control over one’s life and choicesTo save money or spend it on more important thingsTo be a better role model to younger generationsTo be included in more social circlesTo reduce the risk of developing crippling illnesses - like cancer, heart disease or emphysemaA desire to live longerTo eliminate the smell of cigarettes from clothes, breath, skin and homeTo reduce the signs of premature agingTo not have to search for a smoking areaTo improve physical well-being and vitalityTo breathe better and easierTo reduce pressure exerted by family or friendsTo increase the chances of having a complication-free pregnancyTo improve one’s sense of self-discipline and self-esteemAt the request of a physician

Please do not click SEND untill you have answered all the questions.
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