Are You Ready To Quit Smoking?

How often do you think about quitting smoking?
A. All the time
B. Occasionally
C. Rarely
Do you feel concerned about the impact smoking has on your loved ones?
A. Yes, very concerned
B. Somewhat concerned
C. Not really
How often do you feel negative effects from smoking (e.g., shortness of breath, coughing)?
A. Frequently
B. Occasionally
C. Rarely
Have you successfully quit other habits or made big life changes before?
A. Yes, and I feel confident I can do it again
B. I’ve made changes, but it was challenging
C. I struggle with change
How confident do you feel about your ability to quit smoking?
A. Very confident
B. Somewhat confident
C. Not confident at all
Have you tried to quit smoking before? What happened?
A. Yes, and I learned from it
B. Yes, but I struggled and went back
C. No, I haven’t tried yet
How willing are you to explore new methods to help you quit, like hypnosis?
A. Very open to trying new things
B. I’d consider it if I needed help
C. I’m hesitant
Do you believe quitting smoking will significantly improve your life?
A. Absolutely
B. I think so, but I’m not 100% sure
C. I’m not sure
Are you prepared to handle withdrawal symptoms and cravings?
A. Yes, I’ve researched strategies to manage them
B. I’m somewhat prepared, but nervous
C. No, I’m unsure how to handle them
Do you have a support system to encourage you to quit?
A. Yes, I have supportive people in my life
B. Somewhat, but I could use more support
C. Not really
Does the money you spend on smoking inspire you to quit?
A. Yes, the cost is a big motivator
B. I’ve thought about it, but it’s not my main reason
C. I haven’t really considered the financial cost
How do you feel about the smell of smoke on your clothes, hands, or home?
A. I dislike it and want to change
B. I’m indifferent
C. I don’t mind it
How would you feel if you successfully quit smoking?
A. Relieved and proud of myself
B. I think I’d feel good, but I’m unsure
C. I’m not sure how I’d feel
When do you plan to quit smoking?
A. I’m ready to start now
B. Sometime soon, within the next month
C. I haven’t set a date yet
How motivated on a scale of 1 to 5 are you to quit smoking? 1 (not at all motivated) to 5 (very motivated)
1
2
3
4
5
Are you exploring quitting smoking because
You really want to quit once and for all
Other people are pushing you to quit
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