Smoking Cessation Pre-Assessment Questionnaire Corporate

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Thank you for considering the Health Coach Integrative Smoking Cessation Programme! This self-assessment questionnaire will help us to get to know you better. There are no right or wrong answers, simply answer as accurately as possible, for your unique situation.

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Smoking Cessation Pre-Assessment

Please select an answer(s) that best reflects what you think and feel. You can choose more than one answer to each question.

1. How long have you been smoking?

2. How many sticks of cigarettes do you smoke a day on average?

3. Which of the following statements is true for you?

I have given no thought to quitting tobacco use, and have no intention to quit in the near future (within the next 6 months).

I have begun to examine my tobacco use and desire to quit. I'm now weighing the pros and cons of quitting.

I have made a commitment to quit (within the next 30 days) and need help to develop a quit plan for myself.

I already have my own plan for quitting (within the next 6 months).

I have successfully quit and sustained abstinence for at least 6 months

I have tried to quit before but was not able to sustain abstinence.

Other:

Clear selection

4. What are the three biggest sources of pain you feel in relation to your smoking?

I am very much aware of the dangers of smoking and the many negative side effects. However, I still cannot bring myself to quit.

I feel guilty about my smoking habit.

I refrain from smoking when I'm with people who do not smoke. This can be difficult at times.

I feel alienated as a smoker, and even feel like a persecuted minority or outcast at times.

My smoking is causing a strain in my romantic relationship, or with my family.

I feel discriminated against at work because of my smoking habit as I have to take time off to go to a smoking area.

I am fed up with the rudeness and looks given to me by non-smokers when I light up near them.

I am out of control. I tried to quit several times and feel frustrated that I can't seem to maintain abstinence.

I feel that others are judging me because of my habit and inability to quit.

Other:

5. What are your three biggest struggles with quitting?

Smoking helps me deal with stressful situations.

Smoking gives me a pleasant and enjoyable break from work.

Smoking helps me unwind and relax.

Smoking helps me deal with painful or unpleasant situations.

Unpleasant withdrawal symptoms.

I enjoy the physical sensation of lighting and handling a cigarette.

Smoking increases my enjoyment of pleasant experiences.

Smoking helps me feel comfortable in social situations.

Smoking helps me concentrate.

I enjoy hanging out with smoking companions at the smoking area.

Other:

6. If you knew you could not fail, would you want to quit smoking?

Yes, definitely, if I can get the support I need.

Not in the near future, I will choose my own time.

Maybe.

Other:

Clear selection

5. What has been keeping you from making a quit plan so far? Why don't you want to quit? What is the pay-off?

I don't want to give up my old buddies: cigarettes and alcohol

I am addicted. I can't help it.

I feel great with each "hit" of nicotine - gives me enhanced pleasure, decreased anxiety, and a state of relaxation.

Smoking helps me to concentrate.

Smoking reduces the level of stress in my life.

Smoking helps me keep my weight down.

Other:

6. What will your life be like now and in the future if you were able to quit smoking successfully?

I will be happier

I will be healthier and experience less pain and sickness

I will be excited about my life

I will be attractive to others

I will have more energy to do the things I love to do

I will feel less guilty about being a poor example to my children and family

I will feel better about myself

I will have less smoking related health problems

I will have a better quality of life

I will be able to save the money I have to spend on cigarettes now.

Other:

7. What will happen if you continue down the path you're on now? What is the consequence of inaction?

I will be at higher risk of dying before age 65.

I may develop smoking related illnesses such as lung cancer, heart disease.

The illnesses I already have will continue or grow worse

I may not be here for my children and grandchildren

I will continue to feel unattractive

I will have less energy to do the things I love to do

I am likely to spend more time in the hospital.

Each cigarette I smoke costs me 5 to 20 minutes of life.

Other:

YES! I am excited to embark on this journey to good health and vitality!

No. I'm not ready.

Totally.

Clear selection

I am not sure if I can quit successfully. I would like to have a private consultation with the Quit Smoking Coach. My preferred timing: *

First Choice

2nd Choice

3rd Choice

Weekday lunch time

Weekday after work

Others

WhatsApp Contact No:

Full Name:

Preferred Language:

English

Chinese

Malay

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I found out about this program through:

Posters

Other

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Are you a staff of MSD?

Yes

No, I'm from a vendor company.

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If you are a staff of MSD, please tell us which department you are in. If not, please tell us which company you are in. (This is just to help us for billing purposes.)

* All responses will be treated in strict confidence, and will not be divulged to any third party except when analysed as a group without reference to any individual. Please recognize that it is your responsibility to work directly with your health care provider before, during and after seeking nutrition and/or health coaching with Health Coach International. Any information provided is not to be followed without prior approval of your doctor. If you choose to use this information without such approval, you agree to accept responsibility for your decision.

I agree

I disagree

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