Stop Smoking
Stop Smoking
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Email *
Full Name *
Phone number *
Email address *
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? *
Do you live with anyone else who smokes? *
Do any of your work colleague’s smoke? *
Do you smoke at work? *
Have you stopped smoking before? *
If yes, how long did you stop smoking for? *
What method did you use? *
What prompted you to start smoking again? *
What emotions do you associate with the reason why you started smoking? *
Where and when do you have the first cigarette of the day *
Do you smoke after meals? *
Do you smoke more in social situations?
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Do you have any major stresses in your life at present? .If yes, briefly describe below: *
Do you suffer from breathing difficulties? *
Do you suffer from colds, coughs and/or flu? *
Are you health conscious? *
Would you describe your health as: *
Has any member of your family died through smoking-related illnesses? *
What benefit does smoking have for you? *
Why do you want to stop smoking? *
Identifying behavior patterns: Thinking about the reasons or situations why and when you smoke now, please list the three which most apply to you from the following list, or substitute for your *
Use your three responses to complete the following type of sentence: These should be practical and achievable substitutes. Examples are: Instead of smoking when I'm lonely I telephone a friend / go for a walk / talk to the dog                                                              Instead of smoking when I'm walking I enjoy the fresh air / enjoy the view / take deep breaths                             Instead of smoking when I'm in company I concentrate on the people I'm with / feel proud that I'm a non smoker *
Think about your goal date for stopping smoking. If you are an 'all or nothing' type of personality you may be better off 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 *
Now sign this as a commitment to yourself
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