| Name * |
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| Telephone
number * |
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| E-mail
Address: * |
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| Date of
birth * |
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| How would
you rate your personal level of motivation to stop smoking? * |
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| How would
you estimate your ability to be hypnotised if you were asked to guess? * |
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| Do you
live with a long-term partner or spouse? * |
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| Are you
quitting smoking to please someone else? * |
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| Do you
live with a smoker who does NOT want to quit? * |
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| Do you
have any children? * |
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| If you
answered YES to the previous question, how old are they? |
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| How many
times have you tried to quit smoking in the past?
* |
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| How many
times have you successfully quit smoking for more than one month? * |
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| What
brand / type of cigarettes do you smoke? * |
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| How many
cigarettes do you smoke per day on average? * |
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| How many
years have you been smoking? * |
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| How soon
after waking do you have your first cigarette each day? * |
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| In the
past, when you have been ill, have you continued to smoke? * |
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| If you
were asked to try your best NOT to smoke, how long do you think you
would be able to manage without having a cigarette?
* |
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| Which
cigarette, if any, would be the most difficult to give up? For example,
the first of the day, when drinking coffee, during a work break, etc. * |
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| Do you
tend to smoke more in the morning, afternoon or evening? * |
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| How
worried are you about gaining weight after stopping smoking? * |
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| How many
units of alcohol do you consume per week on average? * |
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| Do you
take, or have you ever taken any recreational drugs? * |
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| If you
answered YES to the previous question, please give details ie type, how
frequently, how long since you last did it, etc |
|
| Have you
ever been diagnosed as suffering from depression?
* |
|
| Have you
ever been diagnosed as suffering from any other psychological or
psychiatric condition? * |
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| If you
answered YES to the previous question, please give details |
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| Do you
drink any caffeinated drinks on a regular basis ie tea, coffee, cola,
etc * |
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| If you
answered YES to the previous question, please give details ie what
type, how many cups/cans per day, etc. |
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| Any
further information regarding your decision to quit smoking: |
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| The
details I have given on this form are to the best of my knowledge
accurate and the therapist shall not be held responsible for
difficulties arising due to details I have failed to disclose. * |
I agree |
|
| |
| * Required |
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