Congratulations, You are about to take an active step towards changing your life for good. In the following questionnaire you will be asked to provide details about your smoking behaviour and related data. It takes 5 minutes to complete the form and this information is highly important in order to start preparing the right programme for you. If you prefer not to answer a certain question from any reason, just skip it, we can talk it over in the meeting or over the phone. All information provided by you will be treated with strict confidentiality in accordance with the Australian Psychological Society - Code of Ethics. All questions marked with red star * are mandatories EasyQuit Questionnaire First Name* Surname* Country* Select your current country Australia United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Antilles French Guyana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Island Mexico Micronesia Moldavia Monaco Mongolia Monterrey Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Samoa (United States) Samoa (Western) San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St.Vincent & Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands Wallis and Futuna Island Yemen Yugoslavia Zaire Zambia Zimbabwe State City/Town* Occupation Age* Gender* M   F E-mail* Phone* Home + Work + Mobile + You must provide at least one phone contact. (blank spaces are not valid) Preferred contact times* Day select Weekdays Weekend Any day   Time select Morning: 8am-12pm Noon: 12pm-4pm Evening: 4pm-9pm Other (provide details) How many cigarettes do you smoke a day?* How many years have you been smoking?* Have you tried quitting before?* Never Once A few times Many times I am trying all the time When previously attempting to quit, what was the longest period of time without smoking? select An hour or less A few hours A day A few days A week A few weeks A few months More then a year 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    Did your parents smoke? One of them was a smoker Both were smokers Both were non-smokers If you have a partner does he/she smokes? Never smokes Was a smoker, but quit successfully Is smoking presently If you have a child or children do you smoke in their presence? Yes    No What experience do you have with the following drugs? Alcohol I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Marihuana I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Ecstasy I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Speed I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Sleeping pills I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Valium I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Prozac I never used it I tried it once I tried it a few times I am using it occasionally I am using it frequently Other How much stress do you experience in your professional life? Next to nothing Little Quite a bit Significant amount Too much How much stress do you experience in your private life? Next to nothing Little Quite a bit Significant amount Too much Do you practice any of the following on a regular base? (At least once a week for at least 30 minutes) (You can select more than one) Gym Swimming Jogging Walking / Bush walking Yoga / Pilates Bicycle Other    How would you rate your life from 1-10? (The higher the number you choose, the better you feel in that area) Health & Well-being select 1 2 3 4 5 6 7 8 9 10 Career/Business select 1 2 3 4 5 6 7 8 9 10 Family Life select 1 2 3 4 5 6 7 8 9 10 Relationship select 1 2 3 4 5 6 7 8 9 10 Self-Esteem select 1 2 3 4 5 6 7 8 9 10 Peace of Mind select 1 2 3 4 5 6 7 8 9 10 How important is quitting for you? (Select the phrase that best represents the importance of quitting in your current life or write it down in your own words in the last box) Not really important. I guess I should do it. Important. It is bad for me. Very important. It is very bad for me. Most important. It is killing me. Why do you want to quit smoking? How did you hear about the service? Searching the Internet A flier    Handed to me in the street Placed In my mail box A sales representative visit my home I saw an add in the paper A friend told me about you A client of yours referred me My doctor referred me Other
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