Intake - Questionnaire

First & last name (in that order)

Your full physical address (including postal code)

Your mailing address if different from physical address

Work phone (include area code)

Landline home phone (include area code)

Cell phone (include area code)

Emergency Contact / relationship / telephone number.

(optional) Family Doctor name & tel #

Occupation.

Your PRIMARY email address (privacy assured) We do not sell, rent or share your email.

Medical issues (click what applies to you)

Diagnosed with cardiovascular disease / heart disease
Diagnosed with Chronic obstructive pulmonary disease (COPD)
Diagnosed with anxiety disorder / panic attacks
Diagnosed with depression
Diagnosed with other mental conditions
Diagnosed with diabetes
Diagnosed with high blood pressure
Diagnosed with chronic pain
Diagnosed with asthma
Diagnosed with epilepsy
Diagnosed with migraines
Diagnosed with hearing impairment
Fear of heights
Fear of enclosed places (claustrophobia)
Fear of water (lakes, rivers, oceans, swimming pools etc)

Your SMOKING PROFILE: To assist the hypnotist in customizing your sessions for maximum results, we need as much information as possible. The more information you provide us, the better.

How many times have you tried to quit?

This is my first attempt
As many as 5 times
More than 5 times

If you did manage to quit for awhile...

Was smoke free for less than 7 days
Was smoke free for less than 1 month
Was smoke free for less than 6 months
Was smoke free for 1 or more years

If you wish to elaborate on the times you quit, you may do so here.