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Quit Smoking

A pre-program questionnaire for participants in the Quit Smoking Program

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Question 1 of 11

1. How long have you been smoking?

Question 2 of 11

2. How many cigarettes do you smoke per week?

Question 3 of 11

3. How much do you spend each week on cigarettes?
 

Question 4 of 11

4. Do you have any health issues as a result of smoking
 

Question 5 of 11

5. do you have anxiety or depression?
 

Question 6 of 11

6. have you tried to quit before?
If yes how long were you smoke free  and what process did you use to Quit?
 

Question 7 of 11

7. On a scale of 1-10 how committed are you to quitting right now?

 

Question 8 of 11

8. What would it be worth in $ to stop smoking for
1 year ?
10 years?
The rest of your life?
 

Question 9 of 11

9. Are you prepared to write a testimonial on successful completion of this program?

Question 10 of 11

You best contact phone number

Question 11 of 11

10. Do you know anyone else who would be interested in taking part? 

Confirm and Submit