Questionnaire

Name: _________________________ Occupation: ______________________

Age: ______ Family Status: ____________________

We would be delighted if you could take the time to complete the

following form. Kindly place a check (√) in mention dashes.

Q1. Do you smoke?

Ans. _____ Yes ______ No

Q2. Why did you start smoking?

Ans.__________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________

Q3. Approximately how much do you smoke?

Ans. _______ Cigarettes per day or ________ Cigarettes per week

Q4. How much money you spend on smoking?

Ans. _______ per day or _______ per week

Q5. How many years have you been smoking?

Ans. _____ less then a year _____ 2-3

_____ 3-4 _____ more then 5

Q6. How you feel while smoking?

Ans. ______ Excited _____ Cool _____ Relaxed

______Comfortable ______ Happy

Q7. Do you wish you could stop smoking?

Ans. _____ Yes ______ No ______ Not Sure

Q8. How much time you need to get rid off smoking?

Ans. _____ week or weeks ____ month or months ____year or years

Q9. How do you want to get rid off the smoking?

Ans. ______ Using any other source _______ Yourself

Q10. Which of the following problems are connected with smoking?

Ans. ______ Lung cancer ______ Heart attack ______ Headache ______ Flu

______ Asthma ______ Coughing ______ Weight gain/loss

Q11. Do you snore?

Ans. ______Yes _______ No ______ Not Sure

Q12. Do you have any family members who smoke?

Ans. ______ Brothers and sisters ______ Grandparents ______ Parents

______ Close friends ______ None