Stop Chew Questionnaire

1
What's your name?* This field is required.
First Name
Last Name
2
What's your Email?* This field is required.
example@example.com
3
Best phone number to reach you?* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of birth
Date
Year
Month
Day
6
How old are you?
7
What's your marital status?
Single
Married
Divorced
wish I knew
Widowed
8
GenderYou mostly identify with
MaleFemale
9
How's your general health?
Good
Fair
Poor
Could be much better
10
When was your last physical?
11
Are you currently taking any medications?
Huge
Large
Normal
Small
Ok
Ok
12
In the past 12 months, have you seen a professional for:
Massage Therapy
Nutrition
Acupuncture
Traditional Chinese Medicine
Personal Fitness Training
Stress Management
Yoga
Chiropractor
13
How much do you chew per day?
14
What is the most you've chewed?
15
What age did you start chewing?
16
Why did you start chew?
17
Do you think you addicted to chew?
YESNO
18
What methods (if any) have you used to try to stop chew before?
Patches
Gum
Pills/Lozenges
Acupuncture
Willpower
Hypnosis
19
What is the longest amount of time you've gone without chew?
20
Has your physician recommended that you stop chew?
YESNO
21
When do you reach for chew?
upon walking
with coffee
while driving
on breaks
walking
before meals
during meals
after meals
when drinking
watching TV
after sex
reading
social events
on the phone
before bed
when you awake in the morning
22
I'm tired of being controlled by Chew.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
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It's annoying
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Driving me nuts
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Must change now!
Row 0, Column 3
23
It's time to get healthy again
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
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Driving me nuts
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Must change now!
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24
Concern for future health
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
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Driving me nuts
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Must change now!
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25
I am tired of my cough and frequent colds.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
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Driving me nuts
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Must change now!
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26
I hate this shortness of breath & lack of energy.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
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Must change now!
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27
I don't want to die. and lose 14 years of life that the average chewer forfeits
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
28
I don't want the ones I love to have to watch me die from cancer or emphysema.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
29
I hate being looked down on by others.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
Row 0, Column 0
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
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Must change now!
Row 0, Column 3
30
Planning my life around my habit takes way too much effort.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
31
I hate the smell on my breath.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
32
I'm tired of taking myself away from others to Chew.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
Row 0, Column 0
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Row 0, Column 2
Row 0, Column 3
Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
33
The cost. I have much better things to do with my hard-earned money.
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
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Rate
Didn't Notice
Row 0, Column 0
It's annoying
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Driving me nuts
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Must change now!
Row 0, Column 3
34
To avoid premature aging (grey wrinkled skin, yellow teeth, deep scratchy voice)
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
35
I want to be there for my family
Didn't Notice
It's annoying
Driving me nuts
Must change now!
Rate
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Rate
Didn't Notice
Row 0, Column 0
It's annoying
Row 0, Column 1
Driving me nuts
Row 0, Column 2
Must change now!
Row 0, Column 3
36
Select the 3 most important reasons to become a non-chewer.The top 3 reason only
Controlled by chew
Money
Family
Health
Coughs and Colds
Breathing
Death
Pressure from others
Inconvenience
Smell
Anti-Social
Premature Aging
37
How did you hear about us, or who can we thank?
38
* This field is required.I understand that sessions may be audio or video-recorded and become part of my confidential record. I understand any recordings are not available for release. I acknowledge that it is my responsibility to complete this process as recommended. By agreeing to this form, I confirm that all information is true to the best of my knowledge. By agreeing to this form, I accept responsibility to share with my doctor my use of hypnotism if required by law. Please read and agree to our terms of service and release statement.
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