'Hypnosis to Stop Smoking', Louisville, Kentucky, 'Smoking Cessation', Hypnotherapy, Anne Milligan,

Stop Smoking Questionnaire

Instructions
Please fill out the form below, and click the SUBMIT button at the bottom of the screen to send your questionnaire to Anne Milligan's confidential e-mail.

Your Name:	*
E-mail address and phone number/s.: *
How long have you been smoking?:	*
Why did you start smoking? Did someone you looked up to smoke?: *
Have you tried to stop smoking in the past? What method did you use to stop smoking and what happened?: *
How many cigarettes do you smoke a day?:	*
How much do you pay for a pack of cigarettes? How could you better use the money saved by being a non-smoker?: *
List the three main reasons why you want to stop smoking.:
What fears might you have for quitting smoking?:
Are you currently experiencing any medical problems related to smoking cigarettes? Please specify what they are if so.: *
When, where, and under what circumstances do you find yourself craving cigarettes the most? :
Are you currently under the care of a medical doctor? If so, please specify what you are being treated for.: *
Have you ever been hypnotized before? Please describe your experience/s. :

Confidentiality Consent to use E-mail
Please note that by pressing the "Submit" button below you are giving Anne Milligan authorization to communicate with you by e-mail.

(Fields marked with * are required)