Mind, Body and Spirit working together for total wellness..

 

 

 

 

Stop Smoking Questionaire  

476 Cahaba Park Circle

Birmingham, AL 35242

(205)980-4470

 Full Name:  
Session Objective:  

INSTRUCTIONS:

Below are some statements that describe what some people get out of cigarettes.  How often to you feel this way when you are smoking?  By answering the statements below, you provide us a guide that will enable us to know the most effective way to rid you of the smoking habit permanently.

Click the bubble under the response that best fits you.  The default answer is "always".
No.

QUESTION

Always Frequently Occasionally Seldom Never
1 I smoke cigarettes to perk myself up.
2

I get some enjoyment from the steps I take to light up.
3 I find cigarettes pleasurable.
4 Smoking takes my mind off cares and worries.
5 I really notice it when I'm not smoking.
6 I really notice it when I'm not smoking.
7 Smoking cigarettes gives me a lift.
8 Handling a cigarette is part of the enjoyment of smoking it.
9 Smoking a cigarette is pleasant and relaxing.
10 When I feel uncomfortable or upset, I light a cigarette.
11 I find myself lighting a cigarette when talking on the telephone.
12 I get a gnawing hunger for a cigarette when I haven't smoked for awhile.
13 I smoke cigarettes automatically without being aware of it.
14 I enjoy smoking right after eating a meal.
15 I light up a cigarette when I feel angry about something.
16 I light up a cigarette as soon as I awaken in the morning.
17 When I run out of cigarettes, I find it almost unbearable until I can get some.
18 I light up a cigarette without realizing I already have one burning.
                   

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