Seminar Questionnaire

Stop Drinking Seminar Questionnaire

Please complete the questionnaire below prior to your seminar. If you are an extremely heavy drinker, have experienced delirium tremens or seizures in the past, been hospitalised as a result of alcohol cessation, or are concerned about abrupt cessation, please discuss it with your doctor before using Allen Carr’s Easyway.

First Name*

Last Name*

Email*

Confirm Email*

Do You Know Anyone Who Has Quit Something With Allen Carr’s Easyway?*

Yes

How Did You Hear About Allen Carr’s Easyway Alcohol Seminars?*

What Is Your Preferred Drink?*

Average Consumption Per Week?*

At What Age Did You First Drink Alcohol?*

How Did Your Very First Alcoholic Drink Taste?*

How Many Years Have You Been Drinking Alcohol?*

What Is The Main Reason You Want To Stop Drinking?*

What Benefits Do You Get From Alcohol?*

Are You Stopping Due To Pressure From Others?*

Yes

How Much Does It Take For You To Feel Drunk?*

Have You Ever Had Blackouts (Memory Loss) Due To Drinking?*

Yes

Do You Think You Are:*

Alcoholic

Problem Drinker

Just Want To Stop

What Is The Longest You Have Stopped On Previous Attempts?*

Have You Read Any Allen Carr Books?*

Have You Tried Any Other Method To Stop Drinking?*

Any Other Comments