STOP SMOKING QUESTIONNAIRE

Please fill out the Stop Smoking Questionnaire at least 48 hours before your first session. You may want to print out a copy for yourself. We will be discussing your answers to these questions throughout the program. You’ll also receive a copy via email. Thanks!

How many cigarettes do you smoke each day? What brand? Do you smoke them all the way down? *

Why do you want to quit smoking NOW? *

Who else wants you to quit smoking? *

How many other times have you quit smoking? What methods did you use? How hard or easy was it to stop? *

What made you start again? *

Who else in your family/or circle friends smokes? *

At what age did you start smoking? *

Why did you start? What was the motivation? *

What does smoking represent for you? What do you enjoy about it? *

How do cigarettes make your life easier? *

What are your fears about stopping smoking now? *

What will happen if you DON’T stop smoking? *

What will happen if you DO stop smoking? *

When do you smoke? Choose all times of day & trigger activities that apply to you. *

First thing in the morning
With coffee
After a meal
While driving
Breaks at work / home
While drinking (beer, wine, ect)
Watching TV
When bored
At the computer
On the phone
Before bed
Other….

If you chose “Other” from list of Times you smoke, please describe.

On a scale of 1-10, what is your stress level? (10 = extremely stressful, occasional panic attach / 1 = easy-going, not much stress. Describe briefly. *

What are your 3 greatest strengths &/or achievements in life? *

What is the One thing you like most about yourself? *

Your Name *

E-mail Address: *

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