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Stop Smoking Service Questionnaire

This document is a questionnaire for a stop smoking service. It asks questions to determine if the respondent currently smokes or chews tobacco, if they want to quit, and what support they have tried or would find helpful to quit. It also asks questions about the respondent's home and family situation, their knowledge of quitting resources, and preferences for where to find information on quitting smoking. The goal is to assess the respondent's smoking status and needs in order to provide appropriate support and advice to help them quit successfully with support services.

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سانو روديل
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34 views2 pages

Stop Smoking Service Questionnaire

This document is a questionnaire for a stop smoking service. It asks questions to determine if the respondent currently smokes or chews tobacco, if they want to quit, and what support they have tried or would find helpful to quit. It also asks questions about the respondent's home and family situation, their knowledge of quitting resources, and preferences for where to find information on quitting smoking. The goal is to assess the respondent's smoking status and needs in order to provide appropriate support and advice to help them quit successfully with support services.

Uploaded by

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

Stop smoking service questionnaire

1. Have you ever smoked?


Y

If no, please go to question 9


2. Do you currently smoke?
Y

3. Do you currently chew tobacco?


Y

4. If the answer is yes to question 2 or 3 would you like to quit?


Y

Why would you like to quit?


.
.
.
5. Have you tried to quit in the past, if so how?
..
..
a) Did you get support

b) Did you succeed?

6. If you are wanting to quit what is stopping you from trying to quit right now?
..
..
7. Do you currently have any smoking/tobacco chewing related illnesses? If
so which (optional):
..
..
8. If you are thinking of quitting do you know who to contact for advice?
Y

YOU ARE FOUR TIMES MORE LIKELY TO QUIT WITH SUPPORT


(Please turn overleaf)

9. Is your home/car smoke free?


Y

10. Do you have any children under 5 living in your home?


Y

11. Do you know people that smoke i.e. friends or family?


Y

12. Have you given them any advice on quitting?


Y

13. If yes, what advice have you given them?


..
..
..
14. Do you think there is enough information available on how to quit
smoking?
Y

15. Where would you look for information on how to quit smoking?
GP

Internet

The NHS website

Library

Community centres

Internet other

Other (please state): ......


16. Do you have any other comments about smoking?
..
..
..
..
..
If you want advice on quitting please contact the stop smoking service
on: 01274 202793

Thank you for taking the time to fill in this questionnaire, your feedback is very
useful

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