Stop Smoking Quiz
There are 3 short questionnaires below, which will help me to zero in on the best strategies for helping you quit.

1. “The Fagerstrom Test for Nicotine Dependence” - What is your current level of nicotine dependency?

2. Why Do I Smoke?” Quiz - This test helps us determine whether your smoking habit is more physiologically, psychologically, or socially motivated.

3. Nongard Nicotine Relapse Indicator Checklist - Understanding what and how you think about your tobacco use can help identify the potential triggers or ‘red flags’ that could cause stress or difficulty in the near or even far future.
Email address *
Name *
Your answer
Phone Number (if not given already)
Your answer
1. How soon after waking do you have your first cigarette? *
2. Do you find it difficult to abstain from smoking in places where it is forbidden? *
3. Which cigarette would you hate to give up? *
4. How many cigarettes a day do you smoke? *
5. Do you smoke more frequently in the morning than in the rest of the day? *
6. Do you smoke even though you are sick in bed for most of the day? *
A. I smoke to keep myself from slowing down. *
B. Handling a cigarette is part of the enjoyment of smoking it. *
C. Smoking is pleasant and relaxing. *
D. I light up a cigarette when I feel angry about something. *
E. When I am out of cigarettes, it's near-torture until I can get more. *
F. I smoke automatically, without even being aware of it. *
G. I smoke when people around me are smoking. *
H. I smoke to perk myself up. *
I. Part of my enjoyment from smoking is preparing to light up. *
J. I get pleasure from smoking. *
K. When I feel uncomfortable or upset, I light up a cigarette. *
L. When I'm not smoking a cigarette, I'm very much aware of the fact. *
M. I often light up a cigarette when one is still burning in the ashtray. *
N. I smoke cigarettes with friends when I am having a good time. *
O. When I smoke, part of the enjoyment is watching the smoke as I exhale. *
P. I want a cigarette most often when I am comfortable and relaxed. *
Q. I smoke when I am "blue" and want to take my mind off what's bothering me. *
R. I get a real hunger for a cigarette when I haven't had one in a while. *
S. I've found a cigarette in my mouth and haven't remembered it was there. *
T. I always smoke when I am out with friends at a party, bar, etc. *
U. I always smoke cigarettes to get a lift. *
1. I drink alcoholic beverages more than 3 times per week. *
2. I live with a cigarette smoker. *
3. Others smoke in my work environment. *
4. I smoke more than 40 cigarettes per day *
5. This is my first attempt to quit smoking. *
6. I am facing stressful life events beyond my control at this time. *
7. I would rather risk the damage from smoking than gain 4.5kg of weight. *
8. I like smoking and do not want to quit, even though it will be good for me. *
9. I have tried to quit several times and fear I won't succeed this time. *
10. People won't like me if I don't smoke. *
11. I will be dull and boring if I quit smoking. *
12. If I can cut down to only a few cigarettes a day I will be happy. *
Submit
Never submit passwords through Google Forms.
This form was created inside of EQ Sales & Marketing. Report Abuse