Smoking Questionnaire Home Smoking Questionnaire Contact Smoking Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. POLK HYPNOSIS James Buckland C.H. 863-241-3135 STOP SMOKING QUESTIONNAIRE First and last Name1. Have you experienced Hypnosis before? *2. If yes with whom, when, how was the experience? 3. When don't you smoke? *4. How many do you smoke a day? *5. What pattern of smoking do you do per day ?6. Have you taken time off from smoking cigarettes? *7. If so, how did you stop? *8. If so, why did you go back? *9. What kind of cigarettes did you smoke? 10. You only desire to smoke 4 or 5 times a day. This is how many you really want. All of the others are when you really don't want a cigarette. Can you quit just 4-5 a day? *Optional11. Why do you want to quit? Motivation: *HealthSocialMoneySomeone else wants you to quitOther12. Were you intuitive about what would happen if you continue smoking? *13. Do other people around you smoke? * 14 Are they supportive of you not smoking? *15. On a scale of 1 to 10. With 1 being the least motivated and 10 being the most motivated to eliminate smoking from your life. Where are you on the scale? *16. List of accomplishments (Diplomas (High School etc.), Awards, etc. it doesn't have to be great: 1.2.3.4.5. 17. First experience with cigarettes? When? *18. How long have you been smoking? *Submit
