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Institute of Social and Preventive Medicine - Faculty of Medicine - University of Geneva - Switzerland

Questionnaire on smoking

The following statements describe how you feel today.
Please rate yourself for today:

1 Angry, Irritable, frustrated
2 Anxious, nervous
3 Depressed mood, sad
4 Desire or craving to smoke
5 Difficulty concentrating
6 Appetite, hungry, weight gain
7 Insomnia, sleep problems, awakening at night
8 Restless
9 Impatient
10 Constipation
11 Dizzy, lightheaded
12 Coughing
13 Dreaming or nightmares
14 Nausea or vomiting
15 Sore throat
16 Dreams of smoking
17 Runny nose or flu, sneeze
18 Mouth ulcers
19 Don't feel well, feel like I am becoming sick, malaise
20 Feel weak
22 Less able to perform tasks requiring attention or vigilance
23 Mood swings (=rapid mood changes)
24 Tired, lack of energy
25 Headache
26 Stressed
27 Short of breath
28 Wheezing
29 Muscles stiff and crampy
30 Drowsy, sleepy
31 Diarrhea
32 Sweating
33 Tremor
34 Tingling sensation
35 Phlegm without a cold
36 Mentally sharp
37 I would like to hold a cigarette between my fingers
38 Sense of smell
39 Sense of taste

Here are 2 questions that need measurement, your heart rate and your body weight (both may change after smoking cessation):

How to take your pulse?
There are two pulse points you may use to count your heart beats. Use whichever is easier for you to find:

When to take your pulse?

Heart rate beats per minute
Weight kg + g

or pounds

Here are a few questions about yourself:
Are you ?
When were you born? I was born in
In which country do you live?
Ethnic origin, please pick one category:
Are you of Hispanic origin?
Did you complete high school?
How many school years did you complete? school years
What time is it now on your watch? It is now: o'clock
Have you smoked at least 100 cigarettes in your lifetime?
Do you currently smoke tobacco? a= Yes, I smoke tobacco every day
b= Yes, I smoke tobacco occasionally (not every day)
c= No, I have stopped smoking
d= No, I never was a smoker
In the last 30 days, on how many days have you smoked ? On days/30
Did you smoke tobacco in the past 24 hours?
(Even one puff of cigarette, cigar, pipe, etc.)
How long is it since you last smoked a cigarette? I smoked my last cigarette ago
Do you currently use:
. a nicotine replacement product (nicotine patch, gum, inhaler or tablet), or
. the smoking cessation drug called bupropion (Zyban), or
. the smoking cessation drug called varenicline (Chantix or Champix) ?
Do you currently use smokeless tobacco (snuff or chewing tobacco)?
Do you currently smoke cigars or pipes?
Questions for CURRENT smokers:
=> if you are a FORMER smoker, please click here.
Please rate your addiction to cigarettes on a scale of 0 to 100:

- I am NOT addicted to cigarettes at all = 0
- I am extremely addicted to cigarettes = 100

 Addiction
On average, how many cigarettes do you smoke per day? Cig./day
Usually, how soon after waking up do you smoke your first cigarette? Minutes
In the past 12 months, have you made a serious attempt to quit smoking?
Do you find it difficult to refrain from smoking in places where it is forbidden, e.g. in a church, at the library, in cinema, etc.?
Which cigarette would you hate most to give up?
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Do you smoke when you are so ill that you are in bed most of the day?
If you started to smoke again, after a serious attempt to quit smoking:
When did you relapse to smoking? After trying to quit, I relapsed to smoking on:
Day:
Month:
Year:
Questions for FORMER smokers:
When did you stop smoking? I stopped smoking on:
Day:
Month:
Year:
When was the last time you smoked a cigarette, even a puff? My last puff was on:
Day:
Month:
Year:
Since then, have you smoked any cigar, pipe, or used smokeless tobacco?

Please check that you have answered ALL the questions

Thank you + + +

Created by par , Jun 5, 2008.