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UpperStorey Care Clinic

A Clinic that helps to heal naturally.

Offering a positive approach to health, wellbeing and balance.

Stop Smoking Form

Thank You for taking the time to complete the Stop Smoking Questionnaire with your details.


Once you have clicked the Submit button below your questionnaire will be automatically forwarded to the clinic in preparation for our scheduled Stop Smoking appointment

Gender*
Children*
Did your doctor/dentist recommend that you stop smoking?*
On average how many cigarettes would you say you smoke a day?*
To appear older To appear cool Copy friends/family Feel grown-up To appear tough/macho Be accepted Curiosity Just felt like it Other
I used to smoke (tick as appropriate)*
On a scale of 1 to 10 and 10 is the highest. What number would you say you were on if you had to put a number on your desire to really want to stop smoking? i.e. where a 0 would be "don't really want to quit" and 10 would be "fully committed" to stop*
How did you hear about us?*
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Thank you for contacting us. We will get back to you as soon as possible