welcome

The following questionnaire takes five minutes to complete. You will be asked to provide details about
your smoking behaviour and related data. The information will be used to prepare our first meeting.
All data will be treated with strict confidentiality, in accordance with the -
Australian Psychological Society - Code of Ethics.

Fields marked with a star * are mandatory
easyquit questionaires
First Name*    Surname*    Age*    Gender* M F
Country of Residence*    City/Town*    

Email*    Occupation
Phone*       Home + Work + Mobile +
                      You must provide at least one phone contact!
Preferred contact times    Day   Time

Any comments ?
How many cigarettes do you smoke every day?*

Have you tried quitting before?*

Never
Once
A few times
Many times
I am trying all the time
How many years have you been smoking?*         

 

When previously attempting to quit,
what was the longest period without smoking?

Which of the following methods did you try?
(You can select more than one)

Cold turkey
Cutting down gradually
NRT (Patches / Lozenges / Gum / Inhalator)
Hypnotherapy
Zyban
Quit smoking workshop   
Self help book   
Other   

What experience do you have with the following drugs?
Alcohol
Marihuana
Ecstasy
Speed
Sleeping pills
Valium
Prozac
Other

How would you rate your life from 1-10?
(The higher the number you choose, the better you feel)

Health & Well-being
Career/Business
Family Life
Relationship
Self-Esteem
Peace of Mind
Why do you want to quit smoking?
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