PORCUPINE HEALTH UNIT

QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE

1

FOR CLINIC USE ONLY

Client Name__________________________ File#__________________


A. GENERAL INFORMATION:

Name:

Home Telephone:

Work Telephone:
Can we leave a message at your home indicating we are from the Quit Smoking Clinic?
Yes No
Address: Street:
PO Box: City: Postal Code:
Email Address:
Date of Birth:

Sex: Female Male
Marital Status:
Single
Married /
common law
Divorced
/ Separated
Widowed
Household members: I am (check all
that apply):
Francophone
Pregnant
Aboriginal
17 or younger


Name /
Relationship to you

Age

Smoker:
Yes No
Yes No
Yes No
Work Status:

Working full-time
Working part-time
Self employed
Retired
Disabled
Unemployed
Housewife or househusband
Student
If employed,


Job title:


Employer / School:
Please select the highest level of education you have completed:

Grade School University degree
Graduate school High School
Doctoral College diploma


Name of your Physician/Nurse Practitioner:
Street:
Address: City: Telephone Number:
Postal Code:
Is your doctor/nurse practitioner aware that you are trying to quit? Yes No


PORCUPINE HEALTH UNIT
QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE
2


1. How did you first hear about the Porcupine Health Units Quit Smoking Program?

Doctor Smokers Helpline
Newspaper Ad Pharmacist
TV Pamphlet / Poster
Website Your Workplace
Health Unit Family / Friend
Other (please specify


B. MEDICAL HISTORY:
2. Have you ever been told by a doctor that you had any of the following conditions?


C. SMOKING PATTERN (Fagerstrom)

3. How soon after you wake up do you smoke your first cigarette?

Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes

No Yes
Dont
Know Please list your medications
Heart attack or angina
High blood pressure
Arrhythmias
Diabetes
Leg ulcers
Poor circulation
Peptic ulcer disease
Jaw problems
Mouth or throat inflammation
Allergies or skin sensitivities
Hyperthyroidism
Liver or kidney disease
Depression
Anxiety
Bipolar
Schizophrenia
ADHD
PORCUPINE HEALTH UNIT
QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE
3


4. Do you find it hard not to smoke in places where it is not allowed, like a church, at the
movies, school, bar, restaurant or hospital?

No Yes

5. Which cigarette would you hate the most to give up?

The first one in the morning
Any other one



6. Please check () how many cigarettes you smoke each day?

10 or less 11-20 21-30 31 or more

7. Do you smoke more in the first few hours after waking up than you do during the rest of
the day?
No Yes
8. Do you smoke if you are ill and in bed most of the day?
No Yes


D. SMOKING HISTORY:

9. How old were you when you started smoking regularly?

10. How many cigarettes do you smoke on an average day ?

11. What brand do you smoke now?

12. How long have you been smoking at this level?

13. Do you use tobacco in any other form other than cigarettes? No Yes

If yes, please indicate the form and average daily amount used:

Form Average Daily Amount (s)
Pipes of tobacco Amount of bowls
Cigars Amount of cigars
Chewing tobacco Amount of plugs
Cigarillos Amount of cigarillos


14. If you work, how much do you smoke during your workday?

15. Do you frequently wake-up during the night to smoke?
PORCUPINE HEALTH UNIT
QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE
4

E. QUITTING HISTORY:

16. Have you tried to quit before? No Yes
If yes, which methods have you tried?
( all that apply)
Which methods were you most successful
with? ( all that apply)

Cold turkey Cold turkey
Cutting down gradually Cutting down gradually
Self-help pamphlet Self-help pamphlet
Individual counseling Individual counseling
Support Group Support Group
Acupuncture Acupuncture
Hypnosis Hypnosis
Laser Laser
Nicotine Gum Nicotine Gum
Nicotine Patch Nicotine Patch
Nicotine Lozenge Nicotine Lozenge
Nicotine Inhaler Nicotine Inhaler
Zyban Zyban
Champix Champix
Other (specify) Other (specify)

17. When was your last quit attempt?
Never tried to quit (skip to section F)
Within the last month
Within the last year
Over a year ago
Over 5 years ago

18. Why did you stop at that time?

19. How long did you go without smoking that time?
Less than 1 day
1 day to 1 week
Less than 2 weeks but more than 1 week
Less than 1 month but over 2 weeks
Less than 3 months but over 1 month
Less than 1 year but over 3 months
More than 1 year

20. Why did you start smoking again?
Craving to smoke became too strong
Needed it to cope with pressure and stress
Began smoking at a party or other social situation
Began smoking while drinking alcohol
Other (please specify)

PORCUPINE HEALTH UNIT
QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE
5


21. How many times have you quit smoking for more than 24 hours?

22. What is the longest you have gone without smoking?

F. WHY I SMOKE (Why Test)
Please read each statement, then check ()
the box that matches how you feel about
smoking
Not at all Very much
1 2 3 4 5
A I smoke to keep myself from slowing down
B Handling a cigarette is part of the
enjoyment of smoking it

C Smoking is pleasant and relaxing
D I light up a cigarette when I feel angry
about something

E When Im out of cigarettes, its near-torture
until I can get them

F I smoke automatically, without ever being
aware of it

G I smoke when other people around me are
smoking

H I smoke to perk myself up


I Part of enjoying smoking is preparing to
light up

J I get pleasure from smoking


K When I feel uncomfortable or upset, I light
up a cigarette

L Im very much aware of it when Im not
smoking a cigarette

M I often light up a cigarette while one is still
burning in the ashtray

N I smoke cigarettes with friends when Im
having a good time

O When I smoke, part of my enjoyment is
watching the smoke as I exhale it

P I want a cigarette most often when I am
comfortable and relaxed

Q I smoke when Im blue and want to take
my mind off whats bothering me

R I get a real craving for a cigarette when I
havent had one in a while

S Ive found a cigarette in my mouth and
havent remembered that it was there

T I always smoke when Im out with friends
at a party, bar, etc

U I smoke cigarettes to get a lift


PORCUPINE HEALTH UNIT
QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE
6


G. YOUR FEELINGS AND PLANS ABOUT STOPPING SMOKING

23. Check the box which best describes you

I am not thinking about quitting, certainly not in the next 6 months.
I am thinking about quitting in the next 6 months.
I want to quit within the next month and I want to know more about how to do it.
I have quit smoking for 6 months or less.
I have quit smoking for over 6 months.

24. Importance: Circle the number that best measures how important it is for you to stop
smoking. (1 being not at all and 5 being very important)

1 2 3 4 5


25. Commitment: Circle the number that best measures how committed you are to stop
smoking. (1 being not very committed and 5 being very committed)

1 2 3 4 5

26. Confidence: Rate how confident you are that you will not smoke in these situations:
(1 being not at all confident that you wont smoke and 5 being extremely confident
that you wont smoke)

1 2 3 4 5 With friends at a party
1 2 3 4 5 When I first get up in the morning
1 2 3 4 5 When I am very anxious and stressed
1 2 3 4 5 Over coffee while talking and relaxing
1 2 3 4 5 When I feel I need a lift
1 2 3 4 5 When I am very angry about something or someone
1 2 3 4 5 With my spouse or a close friend who is smoking
1 2 3 4 5 When I realize I havent smoked for a while

27. What benefits do you get from smoking?
28. What harm or negative effects has smoking caused you?

29. Why do you want to stop smoking?
30. What about quitting smoking would be hard for you?
PORCUPINE HEALTH UNIT
QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE
7
31. Are you ready to set a date to quit smoking? No Yes

H. OTHER INFORMATION

32. Are you concerned that your weight will be affected as you quit smoking?

No Yes

Comments:


33. What physical activity do you do regularly?

Walking Jogging
Biking House work
Swimming Gardening
Other


34. Select the quit smoking method(s) you are interested in?

Self-help pamphlets
Individual counseling
Nicotine gum
Nicotine patch
Nicotine inhaler
Nicotine Lozenge
Zyban /Champix
Other (specify)




Freedom of Information Collection Notice: Personal information is collected under
the statutory authority of the Health Protection and Promotion Act, R.S.O. 1990
c.H.7, s.5. This information will be used to provide health services to individuals at
the Porcupine Health Unit Quit Smoking Clinic. Questions about this collection
should be directed to Public Health Nurse at the clinic.





Signature of client Date

(Adapted from the Peel Public Health, Halton Regional Health Department, Toronto Public
Health and the University of Massachusetts Medical School Quit Smoking Programs.)

September 2011 Ce document est disponible en franais
Submit by e-mail