NEGATIVE EFFECTS OF CIGARETTE SMOKING

SURVEY QUESTIONNAIRE

1. Do you smoke every day?

YES
NO

2. How many cigarettes do you smoke per day?

1
2
3 or more

3. How do you rate your current level of craving?

Low
Moderate
High

4. Did smoking cause you any of these problems?

(More than one answer can be selected)
Frequent coughing
Expectoration
Shortness of breath
Wheezes
Haemoptysis
Pain or tightness of the chest