Online Booking form for Smoking Cessation Service (Free of Charge)
This short questionnaire will help to assess your current smoking dependence status. You may also make an online booking.
All the personal information are strictly confidential and would only be used for record, assessment and follow-up purposes.
Please call 31569012/ 66952523 for any inquiry.
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 Name *
Contact No. (Please make sure its correct) *
Cigarette Consumption per DAY/Brand (Including E-cig/Heated Tobacco Products) *
Main reason(s) for quit smoking? (Check ALL that apply)
PART I：Your Smoking Habit
1) How soon after waking do you smoke the first cigarette? *
2) Do you find it difficult to refrain from smoking in places where it is forbidden? (Such as shopping mall, MTR, etc.) *
3) Which cigarette would you find MOST DIFFICULT to give up? *
4) Do you smoke MORE frequently during the hours AFTER waking than the rest of the day? *
5) Do you smoke even when you feel SICK and rest in bed most of the day？ *
6) How many cigarettes do you smoke PER DAY? *
The Test result will be explained during the consultation.
Smoking Cessation Service Centre Options. The centre I want to book an appointment at: *
Date  and Time of appointment you prefer (Please select appointment after 2 working days to 30 days) Our staff will call you to confirm asap . *
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