IMPORTANT: This questionnaire must be completed in one sitting. You cannot save a portion of it and then come back to complete it later. We recommend that you read the entire questionnaire and get familiar with it first, then complete it in one sitting and submit. This questionnaire may take up to 20 minutes to complete. If you prefer, you can right click on the blank part of the page and a window will open, with the option to print this form. You can then complete the paper version and when ready come back to this online form and enter the information. We do not accept digital files of your printed version - we do not accept email attachments. Your TAQ must come from this online form. Thank you.
Your first & last name
Your full mailing address
Your primary email
Your primary telephone number
Have you tried to quit smoking before?
If yes, how many times have you tried?
What methods have you tried? (Check all that applies).
Have you ever quit smoking before? What is the longest you've been smoke free?
How old were you when you started smoking?
Were you raised in a household with one or more smokers?
Do you presently live with one or more smokers?
How many cigarettes do you smoke daily?
What is the total number of years that you have been smoking?
How many cups of coffee do you drink in one day?
If you drink coffee, what do you put in it? (Check all that applies).
How much water do you drink in one day? A typical water bottle is 500 ml. How many bottles or equivalent?
Stress management is a critical component in smoking cessation. To better help the hypnotist help you, what kind of work do you do? Describe it a little.
How would you rate your work stress level?
Stress management is a critical component in smoking cessation. How would you describe your personal / home life?
(Check all that applies) I usually have a cigarette ...
You could be at work, restaurant or on a long flight - when you are in an environment where smoking is prohibited and not acceptable, do you....
You are quitting for the following reasons (check all that applies)
How physically active are you? (check all that applies)
How is your diet? (Check all that applies).
What do you do to relax? (Check all that applies).
If you take vitamins, please check what applies.
Supplements that you are taking that are not listed above.
What is your sleeping habit? (Check all that applies).
What is your experience with hypnosis? (Check all that applies)
Your diagnosed medical condition(s). (Check all that applies).
Any other diagnosed medical / mental conditions? If so, list them here.
Are you taking any prescription drugs? If so, list them here. (Example: Crestor/for cholesterol)
Are you taking over-the-counter non-prescribed drugs? List them here and describe what you are using them for. (example: Tylenol/for headaches)
OPTIONAL: When experiencing success with hypnosis such as quitting smoking, it is quite common for clients to explore other areas that they would like to achieve success with. What other areas would you consider hypnosis for?
OPTIONAL: Are you a consumer of personal development (self-help) material (books, videos, audios). If so which are you familiar with? Check what applies.
OPTIONAL: Other self-help material that you've consumed. List them here.
Why do you want to quit smoking "NOW"?
What will be different this time?
How do you feel when you think about quitting?
How will your life be different when you are a non smoker?
Any additional information that you would like to share? Be brief. We can discuss it at length during your Live Telephone Assessment.
How did you hear of Mike Proulx / HypnoSET?
If you were referred by one of Mike Proulx's clients, please enter their name here. Thank you.
I confirm that all the information is correct and that I have not omitted any key health condition that may impact or interfere with my hypnosis session. I understand that my facilitator is not a medical doctor and that he cannot diagnose disease, prescribe for or treat medical conditions or psychiatric disorders. Hypnosis sessions are not a replacement for any medical treatment.
Mike M. Proulx is a Consulting Hypnotist, certified by the National Guild of Hypnotists (NGH). NGH is the oldest, largest & most prestigious hypnosis training organization in the world – with members in over 80 countries. Mike has taken numerous advanced courses in hypnosis and has been in active practice since 2008. Mike’s specialty is smoking cessation. By completing and submitting this form, you understand and agree that hypnosis is not a guarantee of success. The human mind is incredibly complex, and no one can guarantee results. Even though Mike’s success rate is generally high, results will vary from person to person. You understand and agree that hypnosis is a mind explorative approach for which you assume full responsibility for undertaking. You understand and agree that Mike Proulx cannot be held responsible for any negative impacts (which are extremely rare) that you may encounter as a result of this explorative approach.
*** If after submitting your form, you realize that you forgot something or made a mistake, not to worry. During your live assessment, there will be plenty of opportunities to make corrections and to clarify.