Smoking Cessation

Please fill out the following information prior to visiting our office.
(Note: The information you provide us will only be seen by our office.)

1. First name:	2. Middle initial:
3. Last name:	4. Date of birth:
5. Address:	6. City:
7. Province:	8. Postal code:
9. Phone number (home):	10. Phone number (work):
11. Phone number (cell):	12. E-mail address:
13. Occupation:
14. Are you pregnant? (If yes, treatment will not be administered.) Yes No
15. How did you find out about our clinic?
16. How long have you been smoking?
17. How many cigarettes do you smoke in one day?
18. When do you have your first cigarette of the day?
19. When do you have your last cigarette of the day?
20. Does anyone else in your household smoke?
21. How often do you smoke cigarettes during a typical work day?
22. What triggers are associated with your smoking habits?
23. Have you tried to quit smoking prior to coming to this clinic? If so, when?
24. What techniques have you tried using to quit smoking, if any?
25. Please list two reasons why you feel that you are ready to quit smoking:

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