Stop Smoking Questionnaire

This questionnaire is designed to be filled in by clients before commencing first session.

Your responses to the following questions will enable your therapist to construct and effective program to help you to quit smoking . All information is private and confidential.
Name
Email Address
Age
Marital Status Occupation
Next of Kin Relationship
Is work stressful? Yes No
When did you smoke your first ever cigarette?    Age?
Why did you start?
What do you get from your cigarettes?
Do you know of any person who has died through smoking? Yes No
Do you know someone who is ill now? Yes No
What do family friends think of you smoking?
Any warnings that your health is suffering?
Doctor mentioned your smoking?
How many cigarettes do you smoke a day (approximately)
Where do you smoke most of your cigarettes?
Are you usually in company with other smokers or alone when you smoke? company alone
Do you live with anyone else who smokes? Yes No
Do any of your work colleagues smoke? Yes No
Do you smoke at work? Yes No
Have you stopped smoking before? Yes No
If yes, how long did you stop smoking for?
What method did you use? (Patches, Chewing Gum, Hypnotherapy, Willpower or Other
What prompted you to start smoking again?
What emotions do you associate with the reason why you started smoking? i.e. guilt, comfort, punishment, contentment, stress, peer-pressure, etc.
Where and when do you have the first cigarette of the day?
Do you smoke after meals? Yes No
Do you smoke more in social situations? Yes No
Do you have any major stresses in your life at present?
Do you suffer from breathing difficulties? Yes No
Do you suffer from colds, coughs and/or flu? Yes No
Are you health conscious? Yes No
Would you describe your health as:
Excellent, Good, Fair, Poor
What benefit does smoking have for you?
What frightens you about smoking
What is important to you and why?
Who is important to you and why?
ave you any worry symptoms? Yes No
Do you have any health problems?
Heart Blood Diabetes Asthma Ulcers
How long do you want to live? Why?
Who is responsible for your health?
What will you do as a non smoker that you could not do before?
What will you do with the money that you save?
Do you really wish to commit yourself to stopping smoking? Yes No
What's stopping you?
Why do you want to stop smoking?

Identifying behavior patterns
Thinking about the reasons or situations why and when you smoke.
  • Stressed
  • Angry
  • Lonely
  • Bored
  • Upset
  • Talking on the telephone
  • Driving
  • Relaxing
  • Socializing
  • After lovemaking
  • Thinking
  • Nervous
  • Irritable
  • To escape pressure
  • Talking
  • Walking
  • After meals
  • Happy
now, please list the three which most apply to you from the following list, or substitute for your own
Use your three responses to complete the following type of sentence:
1. Instead of smoking when I now
2. Instead of smoking when I now
3. Instead of smoking when I now
or use the space below to complete your own affirmations
 
Think about your goal date for stopping smoking.
If you are an 'all or nothing' type of personality you may be better of stopping smoking straight away (i.e. after one session of hypnotherapy). However, if you have any stress in your life, or prefer to cut down before quitting, decide on a date and write it in the space provided.
 
I pledge to myself that I will stop smoking on