Smoking Assessment Hi! Just a few questions to help me understand best how to help you become the non-smoker you will become! NameEmail AddressPhoneHow many cigarettes do you smoke in a day?How long have you been smoking?When do you smoke?On wakingAt breakfastAfter mealsDrivingWith coffeeOn the phoneAt workSociallyIn bedOther times or reasons?What's the most important reason(s) for you to become a non-smoker?Controlled by cigarettesMoney/Expense of smokingChildrenSmell of smokingCurrent health problemsHealthy but concerned about your future healthCoughs and coldsBreathingDeath and dyingPressure from other peopleInconvenience of smokingAnti-social pressuresOther reason(s)What other methods have you tried (if any) to stop smoking?Are you currently seeing a doctor other health professional about your smoking?YesNoWhat other information is relevant to your smoking I should know about?Submit your information!