The Effects of Smoking on Lungs and Respiratory Health

Survey Questionnaire

This study aims to determine the effects of smoking on lungs and respiratory health. The respondents
information provided in this survey will be kept confidential and be used only for research purposes. It
will only take 2 minutes to complete this survey.

Name (optional):__________________________________ Sex:_____________________

Age:_________

I.Direction: Put a check mark (✓) in the box that represents your judgement on the quality of the
research question asked about the smoking problem

1. How old were you when to started to smoke?

10-15 year's old. 15-20 year's old 20 year's old above

2. How many packs of cigarettes you can consume in one day?

1 pack a day 2 packs a day 3 or more packs a day

II. Direction: Encircle thee letter of the following questions that can affect you in smoking situation.

1. What was your main reason for initiation of smoking?

a. Stimulation c. Stress/tension e. Friends/social

b. Relaxation/Enjoyment d. Habit/activity f. Other__________

2. Did smoking cause you any of these problems?

A. Frequent coughing B. Expectoration C. Shortness of breath

D. heezes E. Hemoptysis F. Pain or tightness of the chest

3. Do you want to quit smoking?

a. Yes

b. No