MTU HYPNOSIS - Stop Smoking, Vaping, Chewing Intake Form

MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form
Name*
Home Phone*
Format: (000) 000-0000.
Cell*
Please enter a valid phone number.Format: (000) 000-0000.
Work
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YesNo
E-mail*
example@example.com
Address*

Address

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Zip
Emergency Contact*
Phone*
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Age*
Birthdate*

MonthDayYear
Date
SDSep.Wid.Married
If children, what are their ages?
Highest education level completed*
Occupation*
Doctor’s Name *
Phone*
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Complete Address*
YesNo
Indicate any current health problems - any medications currently taking & their purpose*
YesNo
YesNo
Provider name
Phone
Format: (000) 000-0000.
Complete Address
YesNo
YesNo
YesNo
YesNo
How often?
What type?
What do you expect from hypnosis?*
If you have ever been hypnotized: indicate private or group/purpose/result?*
Do you know anyone personally who has used hypnosis to improve or change his or her life?*
How did you find MTU Hypnosis?*
If you have any fears, concerns, or questions about hypnosis — please describe
YesNo
List your e-mail address if you are interested in receiving our e-newsletter
example@example.com
Effectiveness ( your results )Service ( how we respond to your needs )Time ( how fast you get results )Affordable ( what we charge )
How long have you been smoking - vaping - or chewing?*
How often do you use it per day? *
How many times have you tried to quit ?*
List previous efforts you’ve taken to stop using it in the past.*
An Unwanted ExpenseCoughingDiscomfort, Pain, SufferingEmbarrassmentFamily/Work ProblemsFeeling that smoking controls youLimits on Social LifeLow EnergyRun Down FeelingTirednessWinded Breathing
Activities limited or abandoned such as:
Health problems such as:
Is successfully quitting smoking a top priority?*
What new activities will you become involved in after you quit smoking?*
Do other family members smoke, vape or chew?*
Does your family support you in quitting the habit?*
Is your family excited about your quitting the habit with hypnosis?*
Can you remember when you did not use nicotine products?*
What do you think causes you to smoke, vape or chew?*
What is the #1 reason you want to quit?*
What 3-5 positive benefits do you get by eliminating your habit: Example: I am more relaxed and at ease even when dealing with stressful situations.
a*
b*
c*
d
e
AlcoholismAngerAnxiousBed WettingCancer/Chemo/RadiationDrug AddictionFear of Flying/HeightsFeeling OverwhelmedGagging ReflexGamblingHabit ControlHigh Blood PressureIBSImproved ConcentrationInfertilityInsomniaJealousyJob Interview AnxietyLearning/ADDMedical/Dental Procedures Performance AnxietyMemory ImprovementMigrainesMotivationNail Biting/PickingNervous StomachNervous TicsOCDOrganizational SkillsOver-Healing/ScarringPain ManagementPanic AttacksPre/Post SurgeryProcrastinationPTSDPublic SpeakingRelationship IssuesSalesSelf ConfidenceSkin ProblemsSmoking CessationSports ImprovementStress ManagementStutteringTeeth Grinding/Jaw ClenchingTension HeadachesTest Taking/Study HabitsTime ManagementTobacco ChewingVappingVertigoVisualizationWartsWeight ControlNone Of The AboveOther
First & Last Name*
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Date*

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Date
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MTU Hypnosis - Stop Smoking, Vaping, Chewing Intake Form