Smoking Cessation Questionnaire Please enable JavaScript in your browser to complete this form.Name *Date *Tobacco UseHow old were you when you started smoking/chewing?How much do you smoke/chew?What have you done to stop in the past?What has been the longest period of time you were tobacco free?Why do you want to quit?Do you WANT to quit using tobacco?YesNoCan you see yourself as being tobacco free?YesNoHow will your life be different when you are tobacco free?What is your biggest fear about quitting the tobacco habit?What brand of tobacco do you use?What are some of your habits related to your tobacco use?Do you have children?YesNoIf so, how do you feel about them using tobacco?Why did you start using tobacco?Do you live with other users of tobacco?YesNoDo you know of anyone who has quit?YesNoIf so, what happened?Submit
