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Are You Ready To Quit Smoking?
Smoking is more than just a habit – it is nicotine addiction. That is why many smokers find it hard to quit. Take this simple survey to find out if you are ready.
1. I want to quit smoking for my own personal reasons, not because I feel pressured to quit by others.
2. I have a specific plan in mind to successfully quit smoking.
3. I am always looking for new ways to help me not smoke.
4. I want to quit smoking because I worry a lot about how smoking affects my health.
5. I want to quit smoking because I am tired of being a prisoner to my cigarettes.
When you have finished filling out this survey, add up your score and return survey to your health care provider. Together, you can create a plan to help you quit smoking.
COMPLETELY DISAGREE SOMEWHAT DISAGREE NEUTRAL SOMEWHAT AGREE COMPLETELY AGREE
1 2 3 4 5
COMPLETELY DISAGREE
SOMEWHAT DISAGREE NEUTRAL SOMEWHAT AGREE COMPLETELY AGREE
1 2 3 4 5
COMPLETELY DISAGREE
1
SOMEWHAT DISAGREE
2
NEUTRAL
3
SOMEWHAT AGREE
4
COMPLETELY AGREE
5
COMPLETELY DISAGREE
1
SOMEWHAT DISAGREE NEUTRAL
3
SOMEWHAT AGREE
4
COMPLETELY AGREE
5
COMPLETELY DISAGREE
1
SOMEWHAT DISAGREE
2
NEUTRAL
3
SOMEWHAT AGREE
4
COMPLETELY AGREE
5
Total score:
2