About Us
Our Services
How It Works
Success Stories
FAQs
Auriculotherapy Eligibility Test
Menu
About Us
Our Services
How It Works
Success Stories
FAQs
Auriculotherapy Eligibility Test
Get Started
Blank Form (#4)
Laser Auriculotherapy Eligibility Questionnaire
1. How long have you been smoking?
Less than 1 year
1 to 5 years
More than 5 years
2. How many cigarettes do you smoke per day on average?
Less than 5
5 to 10
11 to 20
More than 20
3. Have you tried to quit smoking before?
Yes, multiple times
Yes, once
No
4. If yes, how long did you stay smoke-free?
More than 6 months
1 to 6 months
Less than a month
No attempts
5. What motivates you to quit smoking today?
Personal health
Family/Loved ones
Financial cost
Social pressure
6. Do you have any personal or family history of heart disease, respiratory diseases (asthma, COPD), or cancer?
No
Yes, family history
Yes, personal history
7. Do you experience persistent symptoms related to smoking (chronic cough, shortness of breath, chest pain)?
No
Yes, mild
Yes, moderate to severe
8. Are you currently taking any medications that might affect your smoking cessation (antidepressants, anxiolytics, etc.)?
No
Yes, but compatible with smoking cessation
Yes, requires medical advice before quitting smoking
9. Has your doctor ever advised you to quit smoking for health reasons?
Yes
No
Haven’t consulted a doctor recently
10. Do you associate smoking with stress or anxiety management?
No, not at all
Sometimes
Yes, very often
11. Are you afraid of gaining weight after quitting smoking?
No, not at all
A little
Yes, a lot
12. Do you feel mentally ready to quit smoking?
Yes, absolutely
I’m not sure
No, not yet
13. Are you familiar with auriculotherapy by LLLT laser as a method to quit smoking?
Yes, and I am convinced of its effectiveness
Yes, but I am skeptical
No, I don’t know about it
14. Are you open to trying alternative or complementary medicine to help you quit smoking?
Yes, completely
Yes, but with some doubts
No, I prefer traditional methods
15. Do you think personal motivation is more important than the method used to quit smoking?
Yes, I believe it’s mainly about willpower
I think the method also plays an important role
I rely mainly on the effectiveness of the method
First Name
Last Name
Email
Phone/Mobile
Score
Evaluation of Results:
Textarea
Textarea
Submit My Results and Be Contacted
About Us
Our Services
How It Works
Success Stories
FAQs
About Us
Our Services
How It Works
Success Stories
FAQs
Facebook
Instagram
Linkedin
© 2024 Laser & Stop. All rights reserved.
Terms and Conditions
Privacy Policy
Terms and Conditions
Privacy Policy
