Stop Smoking Questionaire Name Last Name Email Town Telephone Mobile Gender Age today Age when you first smoked Where did you first smoke? (Describe when and where, ie school, work, etc. Why did you start smoking? How many do you smoke a day? 0-5 6-10 10-15 16-20 21-25 26-30 30+ 40+ 50+ 60+How long have you smoked? What do you smoke? Cigarrillos Roll Ups Vape Cigars TuboWhen did you last try to stop smoking? Never tried Within last year Over 5 years ago Within last month Over 1 yearWhat made you want then to stop? How long did you go without smoking that time? Why did you start smoking again? Which method(s) have you tried (Patches, Gum, Cold Turkey, Champix)? Main reason influencing you to stop smoking now? My partner My employer My priest Financial reason My children My doctor The smell Illnes For myselfWhen do you wish to stop smoking? I want to stop now I am planning to stop soonHow soon after you wake up do you smoke your first cigarette? Within 5 minutes 6 - 30 minutes 31-60 minutes After 60 minutesDo you find it difficult to refrain from smoking in places where it is forbidden (restaurant, bar, office etc)? Yes NoDo you continue to smoke if you are ill and in bed? Yes NoDo you smoke more frequently during the first hours after waking than during rest of day? Yes NoWhat are your 3 favourite cigarettes of the day? Which cigarette is the hardest to give up? How do you feel about cigarettes? (friend or foe)? Do you feel you are addicted to nicotine? Do you smoke to the end or stub it out before? Do you enjoy smoking? What worries you about quitting smoking? Are you worried about gaining weight? On average, smoking one pack a day willl cost you 1.800,00€ per year .What would you like to do with the savings? My reasons for being a non smoker.We all have our own reasons for wishing to quit smoking. Maybe for better health, to save money or to look after our family and loved ones. It is vey important for you to think about and recognise your reasoning for doing so. In the below field write a full and complete list, take all the time you need. You will be surprised at all the benefits and improvements to your life you will gain as a non smoker.Below you will find some ideas that may help. My reasons for being a non smoker. Here are some reasons to consider.I want to look, feel, and be healthier?• My chances of having cancer, heart attacks, heart disease, stroke, cataracts, and other diseases will lessen considerably.• I will be less likely to catch colds or the flu and will be able to recover quicker if I do become ill.• I will breathe easier and cough less.• My blood pressure will go down.• My skin will look healthier and I will look more youthful.• My teeth and fingernails will not be stained.• I won't smell of tobacco• I won't have bad breath.Quitting will make you feel better and improve your health. But there are other reasons to quit that you might not have thought about.Want a better lifestyle?• I will have more money to spend.• I can spend more time with family, catch up on work, or dive into my favourite hobby.• I won't have to worry about when I can smoke next or where I can or can't smoke.• My food will taste better.• My clothes will smell better.• My car‚ home‚ and kids won't smell like smoke.• I will be able to smell food, flowers, and other things better.• "I feel wonderful, can breathe, and I can hold my children or grandchildren without having to change my smoky clothes."Want a better family life?• I will set a great example for my kids; it takes a lot of strength to quit.• My friends, family, work colleagues, and other loved ones will be proud of me.• I will protect my friends and family from the dangers of secondhand smoke.• My children will be healthier.• I will have more energy to do the things I love with friends and family.• I will get healthy to make sure I am around to share in my family's special moments.Want a better financial life?When you return to being a non-smoker you will have more money to spend on other things. Take a few moments to calculate your savings over the next year and think aboiut what you would like to use that money for.Your reasons for smoking? Smoking relaxes me I am less anxious I like the taste I like the smell I have got to do something with my hands I feel more confident I have tried to give up and can't Its not a good time I have lots of problems I will put on weight I will be bad humored I don't have the will power I´m free to choose whether I smoke or not I like smoking, its the only pleasure I have Nothing works and treatments can be dangerous I can give up when I want I´m smoking less I don't want to completely give up Got to die of something I've been smoking for 20 years and I'm perfectly alright I don't believe all the bad press about smoking No reason Other reasons(s)My other reasons for wishing to continue smoking Do you suffer from any of the below issues? (Mark all those applicable) Nervousness Marital problems Inability to relax Alcohol abuse Recent divorce Sleeplessness Drug abuse War trauma Depression Compulsive overeating Sexual dysfunction Serious eating disorder Teeth Grinding Compulsive tendencies Codependency Lack of energy Nail biting Inability to focus Death of a loved one Nightmares Abusive home situation Abusive work issue Death of a pet Childhood trauma Lack of success Fear of heights Fear or phobia Poor self-esteem Sexual abuse Poor health Poor memory Chronic painHow did you find us? Surfing the net Facebook Radio Newspaper Business Card Recomendation Personal ContactPersonal contact with whom? Terms and Conditions I agree and confirm that all data stated above is truly given and I understand that the information will be used during my STOP SMOKING session. https:// www.stopsmoking.es/privacy-policy/Texteingabe Send
