THE PATHWAY HYPNOTHERAPY ROOMSStop Smoking with Glen @ The Pathway Hypnotherapy Rooms Name Email Address Phone Client Ref. No. Name Date D.O.B Phone No Marital status Occupation Address How many cigarettes do you smoke in a day? For how many years have you been smoking? When do you smoke?On wakingAt breakfastAfter mealsDrivingWith tea/coffeeOn the phoneAt workIn bedOther (Write Below) When do you smoke? (Write other reason) What’s the most important reason for you stopping? (Tick Min.3)Controlled by CigarettesCoughs and ColdsMoney / Expense of SmokingBreathingChildren / GrandchildrenDeath and DyingSmell of SmokingPressure from othersCurrent Health ProblemsInconvenienceCurrently Healthy but Concerned about FutureAnti-Social What methods have you tried (if any) to stop smoking? Are you currently on any medication? Please list Are you currently under the care of a doctor?YesNo Did your doctor recommend that you stop smoking?YesNo Who refereed you, or how did you hear about us? Date Signature