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Piral Study Questioner

Piral Study Questioner

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Published by helperforeu

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Published by: helperforeu on Feb 01, 2010
Copyright:Attribution Non-commercial


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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. Wy !i! you sta"t smoking?
Q#. App"o$imately o% muc !o you smoke?
Ans. _______ &iga"ettes pe" !ay or ________ &iga"ettes pe" %eek
Q'. (o% muc money you spen! on smoking?
Ans. _______ pe" !ay or _______ pe" %eek
Q). (o% many yea"s a*e you +een smoking?
Ans. _____ less ten a yea" _____ 2,#
_____ #,' _____ mo"e ten )
Q-. (o% you .eel %ile smoking?
Ans. ______ /$cite! _____ &ool _____ 0ela$e!
______&om.o"ta+le ______ (appy
Q1. Do you %is you coul! stop smoking?
Ans. _____ Yes ______ No ______ Not Su"e
Q2. (o% muc time you nee! to get "i! o.. smoking?
Ans. _____ %eek o" %eeks ____ mont o" monts ____yea" o" yea"s
Q3. (o% !o you %ant to get "i! o.. te smoking?
Ans. ______ 4sing any ote" sou"ce _______ You"sel.
Q15. Wic o. te .ollo%ing p"o+lems a"e connecte! %it smoking?
Ans. ______ 6ung cance" ______ (ea"t attack ______ (ea!ace ______ Flu
______ Astma ______ &ouging ______ Weigt gain7loss
Q11. Do you sno"e?
Ans. ______Yes _______ No ______ Not Su"e
Q12. Do you a*e any .amily mem+e"s %o smoke?
Ans. ______ 8"ote"s an! siste"s ______ 9"an!pa"ents ______ :a"ents
______ &lose ."ien!s ______ None

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