Smoking Cessation Questionnaire

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1 Smoking Cessation Questionnaire Congratulations on deciding to become a non-smoker once again. In order that we can support you in achieving your goal, please complete this form as fully as possible to tell us about your smoking habit. In undertaking your smoking cessation therapy the most important thing is that you are totally committed to wanting to stop that old habit once and for all. For that reason I want you to decide to stop only when you are ready. Once you have decided the time that is right for you, please sign the declaration at the bottom of this form and send it back to me. If you have any questions please do get in touch. My role is to make this change as easy for you as possible. Your role is to want it enough! Personal Details Name Home Phone Mobile Phone Address Address Occupation Date Of Birth Marital Status Name and age of partner Does your partner smoke? Y / N Names and ages of children Do any of them smoke? Y / N Names and ages of grandchildren Do any of them smoke? Y / N Please list ALL your interests & hobbies - the things that you really enjoy Please list any dislikes, fears or phobias

2 What s most important to you in your life What do you try to avoid in life? How stressful would you describe your occupation? If stressful, say why? How much do you enjoy your work and why? How long have you worked there? Medical Details GP Name GP Address Details of any medical symptoms you ve experienced recently for example Loss of breath Wheezing Coughing Colds or flu Loss of sex drive Stress Tiredness Lack of concentration Lack of interest in things Details of any medical symptoms you ve experienced recently for example Unexplained pains Difficulty exercising Anxiety Sleep problems Hoarseness in voice Headaches Fuzzy thinking Irritability Inability to relax Details of any current medication or diagnosed medical conditions in the last 18 months

3 Have you ever stopped smoking before? For how long and what methods did you use. Why did you start smoking again? Details of Your Old Smoking Habit How would you describe yourself? What do you believe about your smoking habit? What age did you start smoking? Who were you with? How was that experience for you? (Describe the smoking of your first cigarette in as much detail as you can remember) For what reasons did you start smoking? Peer pressure To be adult or taken seriously To be in control To rebel against authority Fun and social reasons Others, please state How many do you smoke a day and what (cigarettes, cigars, pipes)?

4 Do you use any other recreational drugs? How many units of alcohol do you drink in a week (1 unit = a half pint or small glass of wine or single shot of spirits) What do you get from smoking? Relaxation Time out Concentration Get a break Avoid bad feelings Avoid confrontation / disagreements Feel confident or less nervous De-stress Comfort Other, please state When do you smoke list ALL the times you smoke and your reasons for smoking at those times?

5 What do you enjoy most about smoking? What frightens you most about smoking? What frightens you most about stopping smoking? For what reasons do you want to stop smoking? Do you know someone who has died from smoking? Who and what relationship did you have with them? Do you know someone who is ill now from smoking? Who and what relationship do you have with them? How will you benefit when you stop smoking? List all the benefits you can think of What will you miss about smoking? What can you do instead to get those things?

6 Is there anything you can think of that would stop you becoming a non-smoker again if yes, what? How much do you believe you can be a non-smoker now? How long do you want to live and why? Who is in control of your health and who is responsible for you maintaining your non-smoking behaviour? What will you do with all the money you save? What will you be able to achieve that you currently cannot achieve because of your smoking habit? List as many things as you can think about. Please describe a typical day s eating. What do you eat and at what times? How much water do you drink a day? How many cups of tea or coffee or high energy drinks do you take in a day?

7 Please Add Any Other Information Which You Think Would Be Useful For Us To Know

8 Declaration I.. on this day (date). Sign to commit totally to undertaking this smoking cessation therapy and understand that I am totally responsible for my actions following completion of the session. I will follow the instructions given during the therapy in so far as they are intended to support my smoking cessation and realise that there are no guarantees of success, since ultimate responsibility lies with me. I commit to the tasking that I will be given following the therapy session and am aware that as part of this therapy I am entitled to a free follow up session in the 7 days following my session, should I consider I need it. I know of no reason, medical, psychological or otherwise, why I should not undertake this course of treatment. Signed Dated Print name THANK YOU

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