David Wynn
Quit Smoking Questionnaire
Tel (34) 666 444 360
  • / /
  • Name Smoker? Yes/No
  • Name Gender Age
    Child 1
    Child 2
    Child 3
    Child 4
    Child 5!
    Child 6 !!
  • Name Gender Age
    Grand Child 1
    Grand Child 2
    Grand Child 3
    Grand Child 4
    Grand Child 5
    Grand Child 6
  • Relation Name Age

  • Age when first smoked
    Where did you first smoke
    Why did you start smoking
    Describe when and where, ie school, work, etc.
  • What made you want to stop?
    How long did you go without smoking that time?
    Why did you start smoking again?
    Which method(s) have you tried (Patches, Gum, Cold Turkey, Champix)?
  • What are your 3 favourite cigarettes of the day?
    Which cigarette is the hardest to give up?
    How do you feel about cigarettes? (friend or foe)?
    Do you feel you are addicted to nicotine?
    Do you smoke to the end or stub it out before?
    Do you enjoy smoking?
    What worries you about quitting smoking?
    Are you worried about gaining weight?
    On average, smoking one pack a day willl cost you 1.800,00€ per year .What would you like to do with the savings?
  • Here are some reasons to consider.

    I Want to look, feel, and be healthier?
    • My chances of having cancer, heart attacks, heart disease, stroke, cataracts, and other diseases will lessen considerably.
    • I will be less likely to catch colds or the flu and will be able to recover quicker if I do become ill.
    • I will breathe easier and cough less.
    • My blood pressure will go down.
    • My skin will look healthier and I will look more youthful.
    • My teeth and fingernails will not be stained.
    • I won't smell of tobacco
    • I won't have bad breath.

    Quitting will make you feel better and improve your health. But there are other reasons to quit that you might not have thought about.

    Want a better lifestyle?
    • I will have more money to spend.
    • I can spend more time with family, catch up on work, or dive into my favourite hobby.
    • I won't have to worry about when I can smoke next or where I can or can't smoke.
    • My food will taste better.
    • My clothes will smell better.
    • My car‚ home‚ and kids won't smell like smoke.
    • I will be able to smell food, flowers, and other things better.
    • "I feel wonderful, can breathe, and I can hold my children or grandchildren without having to change my smoky clothes."

    Want a better family life?
    • I will set a great example for my kids; it takes a lot of strength to quit.
    • My friends, family, work colleagues, and other loved ones will be proud of me.
    • I will protect my friends and family from the dangers of secondhand smoke.
    • My children will be healthier.
    • I will have more energy to do the things I love with friends and family.
    • I will get healthy to make sure I am around to share in my family's special moments.

    The list detailing why you want to become a non-smoker, keep in a place where you will see it often, like your car or where you used to keep your cigarettes. When you feel the urge to smoke, take a look at the list to remind yourself why you want to quit.

    When you return to being a non-smoker you will have more money to spend on other things. Take a few moments to calculate your savings over the next year and think aboiut what you would like to use that money for.
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