Wufoo
Smoking Habits Questionnaire
Please answer all these questions to the best of your ability, take your time, thank you.
Name and Email
*
Why do you smoke?
Do you really want to stop?
I know I need to
Yes
Definitely Yes
How many cigarettes do you smoke each day?
At what age did you start smoking?
Have you stopped and started again before?
Yes
No
How did you stop, and what made you start again?
When do you smoke? (e.g. after meals, when I'm stressed, when I drink etc...)
What do you like and dislike about smoking?
Do you have any fears about stopping smoking?
Do Not Fill This Out
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