United Christian Nethersole Community Health Service- Smoking Cessation Service " Quit Easy" - Online Registration form  (Free of Charge)
"Quit Easy" offers 1 week NRT to eligible smokers to provide a quick and easy option to quit smoking.
This short questionnaire helps to assess your smoking habit.                          
All the personal information are confidential and would only be used for record, assessment and follow-up purposes.
Please call 31569012/ 66952523 for any inquiry.
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1. Name (Full name as in your HKID#) Please show HKID card for verification when collecting 1 week NRT   *
2. Phone No. (Please make sure its correct) *
3. Gender *
4. Age *
5. HKID Number ( First 4 digits) *
6. Number of Cigarettes per Day *
PART  I )  Your Smoking Habit (Fagerstrom Test)
1) How many cigarettes do you smoke per day? *
2) How soon after waking do you smoke the first cigarette? *
3) Do you find it difficult to refrain from smoking in places where it is forbidden? (Such as shopping mall, MTR, etc.) *
4) Which cigarette would you find MOST DIFFICULT to give up? *
5) Do you smoke MORE frequently during the hours AFTER waking than the rest of the day? *
6) Do you smoke even when you feel SICK and rest in bed most of the day？ *
PART II) NRT usage assessment
1) Age 16 or above *
2) Pregnant *
3) Breast feeding *
4) Recent stroke , acute myocardial infarction, severe angina, serious cardiac arrhythmia in the past 2 weeks *
5) Any contraindication of use of NRT *
6) Are you an active case of UCN- Smoking Cessation Service *
7) Smoking Cessation Service Centre Options. The centre I want to book an appointment at: *
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