Quit Smoking Questionnaire

North Ryde and Gordon Locations

Phone: 80657701
Mobile: 0403038832

FIND ME ON GOOGLE MAPS

All the below information is required

Name *

Email Address *

Phone Number *

Best Time to Call *

All the below information is optional. Answering these questions will help you focus more effectively on your goal of regaining your self esteem and building your confidence. I strongly recommend you to answer these questions.

Address

Street Address
Address Line 2
City
State/Province/Region
Postal / Zip Code
Country

Alternate Phone

1. How many cigarettes do you smoke a day?

2. How many packs of cigarettes do you smoke a week?

3. How much does it cost you every week?

4. How old were you when you started smoking cigarettes?

5. Why did you start smoking cigarettes?

6. What is the longest period of time that you have been able to stop smoking previously?

7. For what specific reasons do you want to quit cigarettes today? (Briefly summarise)

8. When do you smoke, what are your triggers? Be Specific
Eg (coffee, before/after meals, alcohol, driving, socializing, stress, anxiety, talking on the phone, upon waking up etc.)

9. How long have you been dealing with this situation of wanting to quit cigarettes?

10. What have you done about it so far? (Patches, Nicabate, Cold Turkey etc. )

11. How motivated are you to quit smoking from 0- 10 (10 is highest level of motivation)?

12. Please describe your general health:

13. Please list any ill health effects you are experiencing due to smoking:

You Could Be Free of Smoking In Less Than A Week!

Fill In Your Contact Details To Get Started

Optionally Also Answer The Questions