Intro
Personal
Referral
Medical
Habits
Motivations
Experience
Add-Ons
Reflection
Alpha Lifestyle Center Intake Form
This is the introduction to our program.
Yes, I am very serious about quitting. I trust that Alpha is qualified to help me and I know that being involved in my own recovery is critical. I will prepare for quitting by completing this exercise because I know it is important.
No, I am not committed to quitting. I am unwilling to put effort into preparing to quit. I know that by ignoring program recommendations I am hurting my chances of success, but I don’t care. I understand that guarantees cannot be offered. I plan only to participate minimally and hope for the best.
You must choose one of the answers above to move forward.
Tell us about yourself.
This is step 2
Name:
Age:
Choose
18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Sex:
Choose
Male
Female
Address:
City:
State:
Zip:
Phone:
E-mail:
Employer:
What is
No More Butts Employee Perk Program
?
Employees & family members of registered companies can select laser for weight control ($75 value) or supplements ($50 value) for FREE! Tell your employer about our NO MORE BUTTS Employee Perk Program and earn cash (conditions apply). More information is on our website, or you can get a NO MORE BUTTS brochure at your appointment to take back to your Human Resources or Wellness department at work. Thank you for helping us grow.
Do you participate in a Health Savings or Flex Spending Account?
Did you know you can use an HSA or FSA to pay for your program?
Referral Info
This is step 3
How did you hear about us?
I am a returning customer.
I was referred by a MI customer.
I was referred by a Windsor customer.
Online
Other
Name:
We have a lucractive referral program. If you don't know their full name, we will work with you to try to identify it so that we can send a referral check. We respect your privacy; we will not reveal your name to the person who referred you.
Please tell a Windsor customer to call or e-mail us with their contact information to start receiving referral checks!
Please explain:
Please explain:
Previous Illnesses & Medical Info.
This is step 4
Have you ever had cancer or are you currently being treated for a cancer-related illness?
No
Yes
Laser therapy for nicotine addiction has not been studied in this population specifically, so we request written permission from your physician before delivering low-level laser acupuncture.
I have read and understand this requirement.
Are you taking any
photoactive
or
immunosuppresant
drugs? If yes, please consult your physician if you have any concerns.
Photosensitivity is the amount to which tissue reacts upon receiving photons, especially visible light. Sensitivity of the skin to a light source can take various forms. Particular medications make the skin more sensitive to light; these include most of the tetracycline antibiotics, heart drug amiodarone, and sulfonamides.
In medicine, the term is principally used for abnormal reactions of the skin. There are no published accounts of adverse effects of laser in patients taking photosensitive medication, but if you have any concerns please consult with your physician.
These potential risks are a conservative precaution and have not been completely proven.
Immunosuppressant drugs are a class of drugs that suppress, or reduce, the strength of the body’s immune system. Some of these drugs are used to make the body less likely to reject a transplanted organ, such as a liver, heart, or kidney. These drugs are called anti-rejection drugs. Other immunosuppressant drugs are often used to treat autoimmune disorders such as lupus, psoriasis, and rheumatoid arthritis. If you have any concerns, please consult with your physician.
These potential risks are a conservative precaution and have not been completely proven.
Are you currently being treated for any of the following condition(s)?
We are not a medical facility, but your medical history helps us to individualize the appointment and can often help us bring value to your appointment and your experience with quitting.
Heart Attack / Stroke ►
Diabetes ►
COPD / Emphysema ►
COPD/ASTHMA Logically, you know that quitting is the right way to go if you are suffering from COPD or Asthma, and you’re here because you know that. But did you also know that smoking significantly reduces the effectiveness of both corticosteroids and bronchodilators; the primary treatments for these conditions? Quitting smoking will slow the progression of COPD, and early diagnosis is shown to save existing lung function entirely. For asthmatics, tobacco smoke (including second-hand smoke) is one of the most common triggers for asthma attacks because smoke irritates the airways, making them more swollen, narrow, and filled with more sticky mucus than nonsmokers with asthma — compounding the risk of asthma flare-ups.
Blood Pressure / Cholesterol ►
Anxiety / Depression ►
Are you pregnant?
No
Yes
Congratulations for recognizing the importance of quitting smoking during your pregnancy. Smoking during pregnancy exposes you and your baby to many harmful chemicals which limit the baby's supply of oxygen and the delivery of nutrients. Nicotine permanently damages a baby's brain and lungs. Smoking during pregnancy has also been linked with many health problems, including problems with the placenta, a reduction in birth weight, preterm premature rupture of the membranes, premature birth, certain birth defects and pregnancy loss. Smoking during pregnancy can also affect a baby after he or she is born, increasing the risk of Sudden infant death syndrome (SIDS), colic, asthma and childhood obesity. Please bring a statement from your physician approving you to receive laser therapy to quit smoking.
I have read and understand this requirement.
Let's get to know you.
This is step 5
To assist the technician, which of the following have been negatively affected by your nicotine habit. Check all that apply.
Career
Health
Image
Spouse
Children
Friends
Faith
Wealth
Other
Please press PLAY on the video below!
At what times do you have the greatest urge to smoke/chew? Check all that apply.
Waking up ►
With Coffee ►
After meals
Having a drink
On the phone
At desk/computer
Driving
Watching TV
In bed
Other:
How much do you smoke?
1-5 cigarettes/day
Did you know? 50% of the cardiovascular risk of smoking is in the first 5 cigarettes of the day!
~Half a pack/day
~One pack/day
1-2 Pack/day
More than 2 packs/day
I use smokeless tobacco
I used to smoke/chew; I now vape or use electronic cigarettes
I have only ever used electronic cigarettes
How much do you chew?
Less than one tin/can per week
One tin/can per week (light), ~4 packs/week
Less than one tin/can per day
One tin/can per day (heavy), ~4 packs/day
Approximately, how old were you when you started?
What are your motivations?
This is step 6
I'm here because... (Check all that apply.)
Someone is pressuring me to quit. ►
I have to quit because I'm having surgery. ►
I have to quit (health) but I don't want to; I enjoy it. ►
I want to quit, but I'm not sure I'm ready. ►
I've decided to quit. That's it. I'm done! ►
Tell us about your experiences
This is step 7
What other methods, if any, have you used to quit?
Nicotine Replacement Therapies (patch, gum, inhalers, lozenges) ►
Drugs (Chantix, Zyban, Wellbutrin) ►
Counseling/Support Groups/Classes/Quit Line ►
Alternative methods (acupuncture, hypnosis, laser therapy) ►
Cold Turkey ►
E-Cigarettes/Vaping ►
Other:
How many serious quit attempts have you made in the past?
0
Thank you for trusting us to help you kick the habit. Quitting usually requires some practice, but we think you’ve made a great decision to contact Alpha Lifestyle Center. We are uniquely prepared to help you. We believe you can do this!
1-5
According to research, quitting will require an average of 6-8 attempts, so you have a head start! We are confident that our program will help you beat the odds and that you will achieve freedom from nicotine addiction earlier than most.
6-10
Don’t be discouraged! According to research, quitting will require an average of 6-8 attempts, so you are right on target for being successful!
10+
Don’t worry! In order to become a nonsmoker, you must be perfect at quitting smoking which requires practice! All of that practice was valuable and necessary. Whether you recognize it or not, EVERY quit attempt offered you some experience that will help you be successful.
What is the longest you have remained nicotine-free?
Please be specific in your response, e.g. 4 Years, 3 Weeks, 6 Days, etc.
What was the reason for relapse?
Nicotine withdrawal symptoms during the first week
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Stress
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Alcohol
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Loss of a loved one
We understand how a significant loss can drive a person back to smoking. Now that you’ve had some time to cope with your loss, do you think your loved one is pleased to be the reason that you returned to smoking? Of course not! He/she understands how you have struggled with their loss, is proud of you for quitting again and relieved to no longer serve as your excuse for smoking.
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Divorce/break-up
If you used the pain of a breakup as an excuse to return to smoking, you are crediting your ex with some control over YOUR life, and we know you didn’t mean to do that. Smoking harms you, is costly and makes you less attractive to others, among other things. Your ex doesn’t deserve that kind of control. Congratulations on taking it back!
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Don't remember
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Other
Whatever the reason, relapse has prepared you to deal with it better (or differently) if something similar happens in the future. We will train you to recognize and act on a relapse threat BEFORE it’s too late. You will be equipped with Relapse Prevention Techniques to help you avoid a future relapse, but it will be up to YOU to put them into play.
Do you have many other smokers in your life?
I live with a tobacco user.
Spouse
Friends
Relatives
Coworkers
Neighbors
Neighbors
None
Add-on Treatment.
This is step 8
Would you like additional services/bundle?
Both
Laser add-on for weight control ►
Alpha Accelerator private-label supplement ►
Neither
Let's reflect before we submit.
This is the last step
On a scale 0-10 (0 being not important 10 being very important), how important is quitting smoking to you?
On a scale 0-10 (0 being not confident 10 being very confident), how confident are you in quitting today?
What benefits of quitting do you most look forward to?
Better Breathing
Reduced Health Risks
More Money
Less Nagging
Improved Image
Not Controlled By A Drug
Less Inconvenience
Pet Health
No More Sneaking/Lying
Not Stink
Other
Is there anything else you would like us to know or is there anything about quitting that has you particularly concerned??
Almost done!
Please take time to think about each question before moving on to the next. There are 5 questions to reflect on before hitting submit.
We encourage others to join you during your appointment. However, sometimes the special people in our lives are not the most supportive when it comes to matters of tobacco use and dependence, so it is up to you whether or not you would like them to accompany you into the treatment room. We want you to know that they are welcome, but we will motion you back alone to the treatment room initially.
Got it!
I have reviewed the
program waiver
and I am fully informed about my decision to invest in this program.
I have reviewed the
program waiver
!
When you click submit you will have the opportunity to schedule a brief coaching session (recommended). This is optional.
No thanks. I'm good. See you on my quit date.
Yes, I want to schedule my optional coaching session.