Smoking/chewing Questionnaire

Name

Did your parents smoke/chew?

Does your spouse/significant other smoke? Do your children smoke?

How old were you when you had your first cigarette? What were the circumstances surrounding it?

Did you continue smoking from that point? If not, when and why did you start again?

Why do you smoke? What benefits do you get from it?

What do you fear if you stop smoking?

What are 5 benefits you’d get if you stopped smoking?

How many times have you tried to stop smoking? If so, what is the longest period of time that you have stopped?

What was your level of commitment when you tried to stop on a scale of 0 to 10(10 being best effort)?

Why did you to start smoking again?

What has been your greatest challenge when you have attempted to quit smoking in the past?

Why are you choosing to stop smoking now?

What is your level of commitment now (scale of 0 to 10)?

Is it your intention to stop smoking today? If not, why?

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