Sasha Carrion's Smoking Cessation Form Please help me to help you Stop Smoking Forever. Fill out this Smoking Cessation Form at least two days before our appointment. The more information you give me in the large boxes, the better. I want to make every minute count. I want you to become a NON-Smoker! Name: Phone: Alt. Phone: E-Mail: Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR PW VI Zip Code: Country: United States Mexico Family members who smoke/smoked: Parent/s Spouse Children None Do any of your loved ones have or have had any smoke related health complications? Yes No If so, please explain: Status: Single Living together Married Divorced Have you ever been hypnotized before? Yes No Are you currently under the care of a Physician? No Yes If yes, please provide the Physician's name and City/State Did your Physician recommend that you stop smoking? Yes No As a complementary service to you, do I have permission to inform your doctor of your progress? Yes No What cigarette brand do you use? How many do you smoke a day? How much do you spend on tobacco per month? Have you ever quit? If so, for how long? What methods (if any) have you used to try to stop smoking before? What does smoking do for you? Your Goals: Why do you want to quit? What would it be like for you if you quit? How would it impact your life? Please be descriptive What is your favorite color? Think of a special place that you love to go to where you feel everything is absolutely perfect - just the way you like it. Where is it? What is it about that place that you love so much? Have you ever walked in your sleep during your life? Yes No Have you ever awakened in the middle of the night and felt that you could not move your body and/or talk? Yes No As a teenager, did you feel comfortable or uncomfortable expressing your feelings to one or both your parents? Uncomfortable Comfortable As a child, did you feel that you were more affected by your parents tone of voice, than by what they actually said? Yes No Do you feel that you learn and comprehend better by: (Check all that apply) Seeing Reading Listening Do you find it easy to be at ease and comfortable with your movements, even when faced with unfamiliar people and circumstances? Yes No Is there anything else that you would like to add? PRIVACY POLICY