Free stop smoking analysis.

Please fill in the questionnaire below and one of our consultants will personally analyse your smoking habit and contact you.

First Name:
Surname:
Email Address:
What age did you start smoking?
What age are you now?
How many cigarettes do you smoke on average per day?
How long do you wait before having your first cigarette of the day?
How long have you been thinking about stopping smoking for?

Please rate each of the following on the perceived benefit scale. 1 = Get nothing 10 = Major benefit
	1	2	3	4	5	6	7	8	9	10
Helps me to deal with stressful situations:
Helps me to relax:
Helps me to concentrate:
I enjoy the physical sensation of lighting and handling a cigarette:
Gives me something to do when I am bored:
Helps me feel confident in social or work situations:

Please rate each of the following on the 1- to 10 scale of why you would want to stop smoking. 1 = Doesn't bother me 10 = Really bothers me
	1	2	3	4	5	6	7	8	9	10
I want to improve my health:
I want to save money:
I don't like smelling of cigarettes:
I don't want my children to smoke:

Do you have any of the following associations with smoking, tick all those that apply:
When drinking tea or coffee:			When drinking alcohol:
When socialising:			During or after a meal:
Whilst driving:			During a break at work:
With certain people:			As a reward for completing a task:
Other:

Have you ever tried to stop smoking?
I have never wanted to stop smoking before:			I have wanted to stop, but I have never tried:
I have tried before, without success:			I have stopped before, but started smoking again:

If you knew everything you now know about smoking before you started smoking, would you have smoked:
	Yes			No

Please indicate your current thinking regarding stopping smoking:
I want to stop smoking now:			I want to stop smoking within the next month:
I want to stop smoking at some time in the future but I have not decided when:			I am not sure if I want to stop smoking:

If you indicated you are not sure if you want to stop smoking please indicate below the most appropriate response:
I don't believe I can stop:			I am afraid of failing again:
I cant imagine life without cigarettes:			I enjoy smoking:

What is the most important factor to you in selecting a stop smoking service, tick all those that apply:
Track record / success of the Company:			Price of the course:
Payment terms:			Guarantee provided:
Closeness to your home or work:			Course availability at suitable times:

Town:
Post Code:
Telephone number:
Send this analysis to a friend or colleague. Enter their email address here: