Name

Date

Email Address

Address

City

State

Zip

Home Phone

Cell Phone

Height

Weight

Age

Sex

Marital Status

College Degree

Major

Occupation

Favorite Hobbies

Do you feel stress? Explain

Are you currently under a physicians care?

Do you get angry often?

Are you happy? If not, why?

Have you been hypnotized before? Have you been hypnotized before? YES NO

What were the results?

How long have you been smoking?

How many packs a day?

Is your smoking making you physically uncomfortable? Explain: Is your smoking making you physically uncomfortable? Explain: YES NO

Are you embarrassed by your need for a cigarette? Are you embarrassed by your need for a cigarette? YES NO

Do you feel your smoking controls you? Do you feel your smoking controls you? YES NO

Is successfully quitting smoking a top priority? Is successfully quitting smoking a top priority? YES NO

Did you know hypnosis is 100% safe? Did you know hypnosis is 100% safe? YES NO

Do other family members smoke? Do other family members smoke? YES NO

Does your family support your stop-smoking efforts? Does your family support your stop-smoking efforts? YES NO