SMOKING CESSATION

INITIAL QUESTIONNAIRE

For office use only

Client CHI Leaders Profession Locality
Health Visitor GP Angus
Venue Practice Nurse Specialist Nurse Dundee
Pharmacist Other Perth & Kinross
P2010 / Keep Well Initiative Yes No

CONSENT TO USE THE INFORMATION YOU HAVE GIVEN US

Please read and complete the following form. Please ask if you would like any item to be explained. If you do
not agree to any of the following, you are still entitled to receive help to stop smoking.
Please tick the box beside the statements and sign and date the form.
I am willing for my details to be kept on a confidential database and for the information to be used
anonymously to assess how the stop smoking programme is working. I agree to be contacted in the future in
connection with my smoking (at the end of the programme, at 3 months and 12 months). I agree to my doctor
being contacted regarding my treatment and progress with giving up smoking.
Please tick one box.
I agree I do not agree
Signature Date

YOUR DETAILS (please tick box / complete)

Title Mr Mrs Miss Ms Dr Other
First Name Surname
Date of Birth (dd/mm/yyyy) / / Gender Male Female
Address

Post Code
Home Work Mobile
Tel Nos
Pregnant at quit date? Yes No
Which of the following best describes your ethnic origin? (please tick one)
White Scottish White Other British White Irish White Other
Asian Indian Asian Pakistani Asian Bangladeshi Asian Chinese
Asian Other Black Caribbean Black African Black Other
Mixed (please specify) Other (please specify)
Do you receive free prescriptions? Yes No
Employment Status (please tick one)
In paid employment Unemployed Retired
Homemaker / Full time Permanently sick or
Full time student parent / Carer Disabled
Other (please specify)
Please turn over for questions about your smoking habit
11.2006
About your smoking habit

11.2006
How soon after waking do you usually smoke your first cigarette? (tick one)
Within 5 minutes
6 – 30 minutes
31 – 60 minutes
After one hour
On average how many cigarettes do you smoke a day? (tick one)
10 or less
11 – 20
21 – 30
More than 30
How easy or difficult would it be to go without smoking for a whole day? (tick one)
Very easy
Fairly easy
Fairly difficult
Very difficult
How many times have you tried to quit smoking in the past year? (tick one)
No Quit attempts
Once
2 or 3 times
4 or more times
Are you currently using any pharmaceutical aids?
Nicotine Replacement Therapy
Bupropion (Zyban)
No
In what way are you receiving support for smoking cessation?
Group support
One-to-one sessions
Buddy scheme
Couple/Family based support
Pharmacy scheme including support
Telephone support
Other (please specify)

QUIT DATE (dd/mm/yyyy) / /

Data Confidentiality and Security Statement

The information provided by you will be held in a secure environment in accordance with the Data
Protection Act (1998). The information will only be used to assess the outcome of this project and no
details will be passed on to any organisations who are not involved in the outcomes assessment.

Please return completed form to:

Clinical Audit Office, TORT Centre, Ninewells Hospital, Dundee DD1 9SY

11.2006