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Smoker Self-Assessment Guide

The document is a smoke free assessment for a patient that has been a smoker for over 10-20 years. It asks questions about when and why they started smoking, who else smokes, how much they smoke per day, when they typically smoke, previous attempts to quit and what led those attempts to fail. It concludes by asking why they want to quit now, what will be different this time, how they feel about quitting and how their life will be different as a non-smoker.

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blackvenum
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142 views2 pages

Smoker Self-Assessment Guide

The document is a smoke free assessment for a patient that has been a smoker for over 10-20 years. It asks questions about when and why they started smoking, who else smokes, how much they smoke per day, when they typically smoke, previous attempts to quit and what led those attempts to fail. It concludes by asking why they want to quit now, what will be different this time, how they feel about quitting and how their life will be different as a non-smoker.

Uploaded by

blackvenum
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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SMOKE FREE ASSESSMENT

Name_____________________________ Today’s Date __________ DOB ___________

1) How long have you been a smoker?


a) 1-5 years
b) 5-10 years
c) 10-20 years
d) As long as I can remember

2) What was significant about the time that you began smoking?
___________________________________________________________________________________

___________________________________________________________________________________

3) What significant others are smokers?

(Circle all that apply)


a) Spouse/Partner
b) Child(ren)
c) Extended family
d) Close friends

3) What do you gain from smoking?

___________________________________________________________________________________

4) How much do you smoke per day?

___________________________________________________________________________________

5) When do you smoke?

(Circle all that apply)


a) First thing in the morning
b) After meals
c) While driving
d) At work
e) When consuming alcohol
e) During stressful situations
f) When bored
g) When depressed
h) Other

___________________________________________________________________________________

___________________________________________________________________________________

6) Have you tried to stop smoking previously? If so, please provide details i.e. how long did you stop and what
caused you to start again.
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

7) What do you think led to these attempts not being successful?

(You may circle more than one)


a) No willpower
b) Easily influenced
c) Fearful of being a non-smoker
d) Lack of self-worth
e) Depression

8) Why do you want to quit smoking now?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

9) What will be different this time?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

10) How do you feel when you think about quitting?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

12) How will your life be different when you are a non smoker?
___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

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