「預約快」服務 (費用全免) Quitnow Express - Online Booking for Smoking Cessation Service (Free of Charge)
這份問卷讓吸煙者了解現時的煙癮程度及對應的戒煙方法，並提供快速預約戒煙諮詢服務。
所有個人資料絕對保密，只作紀錄、評估及提供戒煙服務之用。
如有疑問，可致電2332 8977 或 whatsapp5507 5506與東華三院戒煙綜合服務中心查詢核實，或瀏覽中心網址 http://icsc.tungwahcsd.org/

This short questionnaire helps to assess your smoking habit. You may also make an online booking here.
All the personal information are strictly confidential and would only be used for record, assessment and follow-up purposes. Please reach us at 2332 8977 or whatsapp5507 5506 for any inquiry, or visit our homepage at http://icsc.tungwahcsd.org/
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姓名 / Name *
聯絡電話 / Phone no. *
每日吸煙支數/品牌(包括電子煙及加熱煙) Cigarette Consumption per DAY/Brand (Including E-cig/Heated Tobacco Products) *
推動你戒煙的原因是？ / Why do you want to quit?
1) 你起床後多久便吸第一支煙? / How soon after waking do you smoke the first cigarette? *
2) 當你身處非吸煙區內(例:商場/地鐵/電梯內)，會否感到難於忍住不吸煙？ / Do you find it difficult to refrain from smoking in places where it is forbidden? (Such as shopping mall, MTR, etc.) *
3) 你覺得哪一支煙最難放棄? / Which cigarette would you find MOST DIFFICULT to give up? *
4) 在起床後數小時你吸煙次數是否較其他時段頻密? / Do you smoke MORE frequently during the hours AFTER waking than the rest of the day? *
5) 當你患病至大部份時間臥床時，是否仍會吸煙? / Do you smoke even when you feel SICK and Rest in bed most of the day？ *
6) 你每日吸多少支煙? / How many cigarettes do you smoke PER DAY? *
尼古丁成癮測試結果 / Result of the Nicotine Dependency Test (For Q1 & Q6: a=3 b=2 c=1 d=0; for Q2-5: a=1 b=0. Total score: 0-3= Mlld; 4-5 = Moderate; 6-10 = Severe)
請問你如何得知本中心的戒煙服務？ / How did you hear about us? *
系統可提供預約的日期時間及服務地點
預約於以下地點開始戒煙 / The centre I prefer： *
請問你透過哪個途徑知道戒煙中心的服務? *
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