Why smokers smoke
Bill's BIO
Lynnwood Location
Quit at Home

Confidential  Smoking Questionnaire

Your success is our #1 Priority. Help us to help you attain that success by filling out this questionnaire. The Questionnaire will become part of your file, it is important for us in the process of helping you become a non-smoker forever.


Address, City, State, Zip:

Home Phone:
Mobile Phone:
 Birthday:  E-mail:  

Are you Currently Taking any Pain Medication or Anti-Depressants?

How Many Cigarettes Do You Smoke a Day? What Brand?
How much would you estimate that you spend on cigarettes each month:
What Age Did You Start Smoking & Why:
What Methods (If Any) Have you Used to Try to Reduce  Smoking Before?
Have You Ever gone for More Than a Month? (List the Method Used)
Why Did You Start Again? List Reasons for Starting Again
At IGHWA, we believe that when you agree to stop smoking, you are making a commitment to become a healthier individual. Remember every time you do something positive you are reminding yourself that you have control of your life.
List 3 new healthy things you can do when you reduce smoking, check from the below list or add your own plans to develop a new healthier you.
Drink 64 oz. of  Water a Day Daily Exercise Practice Deep Breathing
Eat Breakfast Reduce Sugar Intake Go Outside, Get Light in Your Eyes, it Can Greatly Improve Your Mood!
Take Vitamins Cut Back on Alcohol

The Best Thing: a Brisk 20 Minute Walk Outside, Every Day, Rain or Shine!
On a Scale of 1-10 How Committed are you to Reduce  Smoking Today:

Reasons to Reduce Smoking

Below I have listed 12 common reasons people want to reduce smoking. Pick out the 3-4 most popular or embarrassing reasons that cause you to realize that now is the time to quit smoking. You can also add your own. List below according to importance to you. If Health is your most important reason, list it first. I will empathize the reasons that are important to you during the hypnosis session.
Reason #1: Reason #2:
Reason #3: Reason #4:

1. Controlled By Cigarettes
2. Money or Expense
3. Children or Grandchildren
4. Health

5. Coughs & Colds
6. Breathing
7. Inconvenience
8. Death & Dying
9. Pressure from Others
10. Smell of Smoking
11. Antisocial
12. Premature Aging
Please Type Your Name as a Confirmation of Filling out this form.