Smoking Cessation Form Name :*YOUR SMOKING HABITS : Please think about the following questions and answer all questions as fully as possible. Do not rush your answers as this information is extremely important.When did you start smoking?*What was the first one like?*What was going on in your life at the time? Please provide as much detail as possible. (Exams, trauma, bullying, peer pressure etc)What do you smoke? Cigarettes, Hand Rolled, Cannabis etc?*How many do you smoke per day?*When do you have your first cigarette of the day?*And when do you have your last cigarette of the day?*When else do you smoke? (With coffee, with alcohol, stressed or anxious, detail social occasions etc)*When do you smoke more?*Please list all of your smoking triggers including situations, times, people, occasions etc :Please detail all of the names and relationships of people close to you who smoke :Please detail the social support (if any) you have post retreat to ensure your success?Are there any times when you don't smoke?*Do you smoke in your car?* Yes No Do you smoke in your house?* Yes No Do you smoke at work?* Yes No Are there any places where you don't smoke?*Do you think about smoking when you're in these places? Yes No What do you get from smoking? (Relaxation, time out, confidence, repressing deep emotions etc)*What do you like about smoking?*What do you dislike about smoking?*What fears do you have about becoming a non-smoker?What are your reasons for becoming a non-smoker?If you became a non-smoker how would it benefit your life? Please describe in full detail.*Have you ever stopped smoking before? If so what happened? Why did you start smoking again?*Did you substitute smoking with anything else? (food, alcohol etc)If you have not attempted to become a non-smoker before then what are your reasons for this?Is there anything else you feel you need to tell us? Δ
