- LifeStyle by Choice -  
                                                                             Tobacco Cessation                           
                                                               (ALL INFORMATION IS CONFIDENTIAL

NAME __________________________________________(NICK NAME)_______________ DATE _____________

STREET ADDRESS __________________________________________ STATE _____         ZIP _______________

E-MAIL ADDRESS________________________________________________________

HOME PHONE _____ ______________     CELL PHONE _____ ______________

I give permission to be contacted via e-mail: YES _____   NO _____  Home Phone: YES _____  NO _____          
Cell Phone: YES _____    NO _____

BIRTHDATE _____________________   Age _____   MALE _____     FEMALE _____

EMERGENCY CONTACT _________________________________________ PHONE _____

Have you been hypnotized before? _____ When __________ Results ___________________________________________

At what age did you start using tobacco products? _____

Did your mother or father use tobacco products?  Mom _____    Dad _____   Comment ___________________________   

Will any other member of your household still be using tobacco products? _____  Who? _____________________________

Have you used other types of treatment for the above issue? YES _____  NO _____
If you have please indicate the type of treatment and its effectiveness:

Are you experiencing any mental health issues at this time? YES ______            NO ______            
      Please explain below:

Are you taking medication for the above?  YES _____  NO _____           Please explain type(s) below:

Have you ever been treated for any of the following?   CHECK IF YES.
Arthritis _____  Diabetes _____  High Blood Pressure _____  Heart trouble _____  Seizures/Epilepsy _____ Obesity_____ 
Anxiety _____ Stress _____ Depression _____ Broken Bones _____ Other ______________________________________

Do you feel that you can gain control of the issue that you are here for today? YES _____  NO _____    EXPLAIN BELOW


I am willing to be guided through mental and physical relaxation techniques, visual imagery, hypnosis, and or
Neuro-Linguistic Programming (NLP). I understand that there are no guarantees for changing human behavior through
this process. I also understand that the services I purchase from LifeStyle by Choice, LLC are not to be used as a
substitute or replacement for professional medical or mental health advice or care.       

SIGNATURE __________________________________________     DATE ______________

LifeStyle by Choice, LLC
Page 2

Name: ________________________________________        Date: ___________

Why did you start smoking?

Where, what locations, do you smoke throughout your day?

What time(s) of the day do you smoke?

At what time and where do you have your first cigarette?

TRIGGERS              (Leave this part  blank – do not write below this sentence)

Daily Triggers –

Sporadic Triggers – 

Emergency & Instant Triggers -