Tobacco use and dependence treatment questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The purpose of this questionnaire is to:
1) Help the Washington State Department of Health (DOH) understand how health care providers approach tobacco use and dependence treatment with their clients/patients; and
2) Inform the development of relevant client and provider resources.

The questionnaire will take approximately 5-10 minutes to complete, and your responses will be anonymous, unless you choose to provide your email address at the end.
If you have any questions, please contact Nick Fradkin at nick.fradkin@doh.wa.gov.

Thank you for your participation!

How often do you ask your clients if they use tobacco?

Never

Only at the first appointment (e.g., at intake)

At least once per year (e.g., during an annual exam)

At every appointment, but only when clients have indicated using tobacco in the past

At every appointment, regardless of past client responses; it's part of my routine workflow

Other:

Clear selection

How much do you agree or disagree with this statement? “It is my professional responsibility to advise clients who use tobacco to quit."

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Clear selection

When was the last time you counseled a client on their tobacco use?

Never

In the last week

In the last month

In the last two to six months

More than six months ago

Other:

Clear selection

Do you refer your clients to any tobacco cessation materials or services? If so, what are they?

Have you heard of the Washington State Tobacco Quitline?

Yes

Clear selection

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms