Clone of Smoking: Fagerstrom test for Nicotine Dependence

1

This brief screening helps you understand your level of nicotine dependence and provides guidance on next steps.

2

Name Optional

First Name

Last Name

3

Email Provide email (optional) to receive your results and resources about next step

example@example.com

4

How soon after waking do you smoke your first cigarette?* This field is required.

Within 5 Minutes

5 - 30 Minutes

31 - 60 Minutes

5

Do you find difficult to refrain from smoking in places where it is forbidden ? e.g. Church, Library etc* This field is required.

Yes

No

6

Which Cigarette would you hate to give up?* This field is required.

The first in the morning

Any other

7

How many cigarette a day do you smoke?* This field is required.

10 or Less

11 - 20

21 - 30

31 or More

8

Do you smoke more frequently in morning?* This field is required.

Yes

No

9

Do you smoke even if you are sick in bed most of the days?* This field is required.

Yes

No

10

Total Score