STOP SMOKING REGISTRATION FORM
To assist us with the preview of your personal information and expedite the consultation, please complete this registration form.
Your success is our #1 priority. Assist us in helping you to attain that success by filling out this questionnaire as completely as possible. This information will be kept
strictly confidential
.
Date:
Name:
Marital Status:
Address:
City/State/Zip:
DOB:
Age:
Occupation:
Phones/Contact:
Home:
Work:
Cell:
Email:
Method of Payment:
Cash
Check
VISA
MasterCard
Driver's License #
(if paying by check):
State:
Have you ever seen a
(check all that apply)
Psychologist
Counselor
If yes, please give their name(s):
Where did you hear about us?
(check all that apply)
Newspaper
TV
Yellow Pages
Radio
Physicial Referral
Web Site
Other
(specify)
How were you referred to Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location
(City/State/Zip)
:
Do you object to us contacting him or her about your success?
Yes
No
Do you spend more than $100 a month on smoking?
Yes
No
Describe how smoking controls or interferes in your life?
Which of these fears do you have of stopping smoking?
(Please check all that apply)
:
Weight Gain
Withdrawal
Giving Up Best Friend/Crutch
None
Do other members of your family smoke?
Yes
No
Do you have a smoking related illness?
Yes
No
Please Explain:
How many cigarettes/pack(s) per day?
Number Years Smoking?
Circle the strongest desire to stop smoking, with 10 equaling the strongest.
1
2
3
4
5
6
7
8
9
10
List three reasons why you want to stop smoking:
1.
2.
3.
List three places or situations in which you smoke the most:
1.
2.
3.
What methods have you used to stop smoking before?
Did you stop?
Yes
No
For how long?
Have you ever experienced a seizure?
Yes
No
Do you have any of these symptoms for which counseling may be useful?
(Check all that apply)
Weight Loss
Pain Management
Sexual Dysfunction
Depression/Anxiety
Excessive Drinking
Anger
Nail Biting
Phobias/Fears
Insomnia
Stress
Overcoming A Breakup
Memory
For Weight Loss Only
Our unique program can quickly eliminate the cravings for unhealthy foods; reduce portions, and stops eating from stress and boredom.
Give three reasons why you are overweight?
1.
2.
3.
How much weight have you decided to lose?
If you successfully lost 20 lbs. or more in the past, how did you do it?
Please submit and bring in this form to your consultation.