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.
Last Name:______________________ First Name______________________________
Address: _______________________________________________________________
_______________________________________________________________________
Phone Number: Home______________________ Cell___________________________
Where did you hear about us? (Circle all that apply)
Newspaper TV Yellow Pages Radio
How were you referred to our office? ________________________________________
Who is your physician and what is their specialty?______________________________
Physician’s office location (City/State) _______________________________________
Do you object to us contacting him or her about your success? ____________________
Do you spend more than $100 a month on smoking? (See chart below)_______________
Do you feel that smoking controls or interferes in your life? _______________________
Which of these fears do you have of stopping smoking? (Please circle all that apply):
Weight Gain Withdrawal Giving Up Best Friend/Crutch None
Do other members of your family smoke? _____________________________________
If Yes who? _____________________________________________________________
Do you have a smoking related illness?________________________________________
If Yes Please Explain:______________________________________________________
How many cigarettes per day do you smoke?___________________________________
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
What methods have you used to stop smoking before?____________________________
________________________________________________________________________
Did you stop?____________________________________________________________
For how long?____________________________________________________________
Cigarette Smoking Cost:
1 Pack/day= $6.00 = $182/mo = $2,188/yr = $10,940/5 yr. = $21,880/10 yr.
2 Pack/day=$12.00 = $364/mo = $4,376/yr = $21,880/5 yr. = $43,760/10 yr.
Based on a cost of $6.00 per pack of cigarettes