Smoke Cessation Clinic Assessment Form

Smoke Cessation Clinic Assessment Form

Anyone who smoke cigarettes or use tobacco products and wants to quit can join our smoke cessation programme.
We are here to help you quit smoking and we would like to learn about you and your tobacco use. Your response on this form will be kept confidential. If you have any questions when filling out this form, please kindly contact us at 0811 777 5391
REGISTRATION INFORMATION
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
YOUR CURRENT TOBACCO USE
What types of tobacco do you use now or in the past 30 days?

CigarettesCigars, Cigarillos or Little cigars
What type of smoker are you?

HabitualSocialStressOther
How many cigarette do you smoke per day on the day that you smoke?

10 or fewer cigarette11-20 cigarette21-30 cigarettes31 or more cigarette
YOUR QUITTING PLANS AND EXPERIENCES
Which of the following best describes your plans for tobacco use at this time? (tick one)

I am a tobacco user and I have decided to quit NOWI don’t know/not sure/I am not ready to quitI want to cut down my tobacco use
How many times have you tried to quit in the past?

None1 time2 times3 or more times

How confident are you that you can quit this time if supported and given help? (Click any number between 0 and 10, with 0 being “not at all confident” and 10 being “highly confident”)

	0	1	2	3	4	5	6	7	8	9	10
How confident are you that you can quitService Quality

ABOUT YOU
What is your date of birth?

MonthDayYear
Date
Are you male or female (tick one)

MaleFemale
Number of People in your household?
Does anyone else in your household smoke?

YesNo
If yes, are they willing to quit smoking too?

YesNo
How much do you spend on Smoking annually?

Under 100k100 – 200k200- 400kOver 400k
Should be Empty:

Smoke Cessation Clinic Assessment Form

REGISTRATION INFORMATION

YOUR CURRENT TOBACCO USE

YOUR QUITTING PLANS AND EXPERIENCES

ABOUT YOU