Smoking Cessation Questionnaire

Date*

Date

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Country CodePhone Number

Thank you for your interest in our holistic smoking cessation treatment, combining Aculaser and Bach Flowers therapy.

This questionnaire will allow us to know you better and assess if and how we can best help you quit smoking effectively and as comfortably as possible.

Please answer all the questions giving as much information as possible and press SUBMIT.

You will then receive a confirmation email with a copy of your filled questionnaire and Bodywave will contact you shortly after to give you an assessment based on your answers and arrange your first Smoking cessation appointment.

1- How long have you been smoking for?

2- How many cigarettes do you usually smoke per day, and per week?

3- How much is your weekly or monthly budget for cigarettes?

4- How old were you when you first became a regular smoker?

5- Can you explain what were the reasons for your smoking?

6- How is your smoking addiction impacting your life, health, family, etc.?

7- What benefits or positive aspects do you get from smoking?

8- What benefits would you get from quitting?

9- Do you live or work in a smokers environment?

10- Does your environment support your decision to quit smoking (friends, family, colleagues, partner…) and will they support you in your change?

11- Have you tried to quit smoking in the past? If no, go to question 17. If yes, how many times have you tried to quit and failed?

12- What methods have you used in the past to help you quit smoking?

13- How long were you smoke free between 2 smoking periods?

14- What external situations or circumstances triggered you to go back to smoking after you tried to quit?

15- Can you describe what negative symptoms, sensations or emotions you felt in the past while you were trying to quit?

16- Can you describe what positive symptoms, sensations or emotions you felt in the past once you stopped smoking?

17- What made you decide to seek help in quitting and to contact Bodywave?

18- In your opinion, what could eventually make you fail and go back to smoking after this treatment?

19- Do you have a tendency to turn to work, alcohol, drugs, food or other comforting activities or substances when you’re feeling down or stressed? If yes, which ones?

20- What do you usually associate cigarettes with in your daily routine? (ex.: coffee, alcohol, socialising, sex…)

21- Are you ready to make definite changes in your habits?

22- Are you easily influenced by others or external factors?

23- Do you consider yourself a strong willed person or do you tend to give up when things get challenging?

24- Apart from your smoking addiction, do you consider yourself a health conscious person, and do you have a health routine?

25- How determined are you to quit smoking for good?

Thank you for taking the time to answer this questionnaire,

You will receive an email with a copy of your answers.

Bodywave will get back to you after reviewing your answers for the next step in your smoking cessation treatment.

Best regards,

Cecile@Bodywave