Smoking Cessation Screening 
Thank your for your interest in the Ceasewell Smoking Wellness Program. Please take the time to complete the initial pre-screening survey to assess your appropriateness for the program. 

Thank you for your interest in our program and the journey to a healthier lifestyle!
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Email *
First and Last Name  *
Date of Birth  *
Gender  *
Ethnicity  *
Race  *
Do you smoke? *
What do you smoke? *
How long have you smoked? *
What age did you start smoking? *
Do you currently use any other drugs/substances? If so, what? *
Do you smoke within 30 minutes of waking up? *
How often do you smoke? *
Do you feel your smoking makes daily life tasks easier or more difficult? *
Do you find yourself unable to function until something is smoked? *
Does smoking impact you emotionally? If so, how? *
Does smoking impact you physically? If so, how? *
Does smoking impact you mentally? If so, how? *
Does smoking impact you financially?  *
How much would you say is spent on average per month surrounding smoking habits? (This includes purchase of materials for smoking) *

Have you experienced additional health complications due to smoking? (asthma, chronic bronchitis, etc) if so, what complications?


Have you ever felt a need to cut down or control smoking but had difficulty? 


Do you find yourself having negative emotions such as anger or sadness when called out about smoking?

How do you deal with stress? *
What is your current stress level on a scale of 1-5? (1 being not stressed at at to 5 being extremely stressed) *
Not stressed
Extremely stressed
Do you smoke more when stressed? *
Have you ever sought therapeutic methods to stop smoking? *
Are you open to using holistic remedies throughout this workshop to help cease smoking? (Meditation, yoga, etc) *
Would you prefer a virtual or in-person workshop? *
Please explain your reasoning for wanting to participate in a smoking cessation workshop.  *
Have you experienced trauma(s) over the course of your life?  *
What are you hoping to gain from this experience? *
Please list current medications being taken and dosage.  *
This workshop is a 5-week program, is that time frame something you feel you can be committed to? *
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