Neuro Stimulation Sound Therapy Week One : CD 1 : Page 4
Smoking Cessation Program : Feedback Form Proceed to Week 2
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The Benefits of Smoking
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Just a few more questions and we will be able to select the Neuro Stimulation Sound Therapy program best able to help you be successful in your smoking cessation.

  • What brand do you smoke :
  • How many cigarettes do you smoke per day ?
  • How many cartons of cigarettes do you smoke a week ?
  • Do you smoke more in the morning, afternoon or evening ?

On a scale of one to ten, please tell us how important each of the following is to your smoking experience ;

  • ____ the stimulant,
  • ____ relaxation,
  • ____ smell / aroma,
  • ____ taste,
  • ____ settle nerves,
  • ____ it makes you feel good about yourself,
  • ____ it takes the edge off,
  • ____ this is a nervous habit,

Please note any additional factor that plays an important role in your smoking experience and rate it on a scale of one to ten as you did on the list above.

Upon completion of this project, please forward your answers to dmaness@brainwaveinstitute.com. Be sure to include your name,
email address and PIN number. If you do not have your PIN number as yet, please note that in your Email and one will be assigned
to you.

Your information will help us taylor the program most suited to your needs.

Proceed to Week 2
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International Brain Wave Institute : Neuro Synergistics
San Antonio, Texas