are you ready to quit smoking - bend memorial clinic€¦ · smoking is more than just a habit –...

Are You Ready To Quit Smoking?

Smoking is more than just a habit – it is nicotine addiction. That is why many smokers find it hard to quit. Take this simple survey to find out if you are ready.

1. I want to quit smoking for my own personal reasons, not because I feel pressured to quit by others.

2. I have a specific plan in mind to successfully quit smoking.

3. I am always looking for new ways to help me not smoke.

4. I want to quit smoking because I worry a lot about how smoking affects my health.

5. I want to quit smoking because I am tired of being a prisoner to my cigarettes.

When you have finished filling out this survey, add up your score and return survey to your health care provider. Together, you can create a plan to help you quit smoking.

COMPLETELY  DISAGREE   SOMEWHAT  DISAGREE   NEUTRAL   SOMEWHAT  AGREE   COMPLETELY  AGREE  

1   2   3   4   5  

COMPLETELY  DISAGREE  

SOMEWHAT  DISAGREE   NEUTRAL   SOMEWHAT  AGREE   COMPLETELY  AGREE  

1   2   3   4   5  

COMPLETELY  DISAGREE  

  1  

SOMEWHAT  DISAGREE  

2  

NEUTRAL  

3  

SOMEWHAT  AGREE  

4  

COMPLETELY  AGREE  

5  

COMPLETELY  DISAGREE  

1  

SOMEWHAT  DISAGREE   NEUTRAL  

3  

SOMEWHAT  AGREE  

4  

COMPLETELY  AGREE  

5  

COMPLETELY  DISAGREE  

1  

SOMEWHAT  DISAGREE  

2  

NEUTRAL  

3  

SOMEWHAT  AGREE  

4  

COMPLETELY  AGREE  

5  

Total  score:

2