Smoking History

Please take a few moments to complete this brief history to tell me a bit of yourself, your smoking habits, and any other information you would like to add. This will better assist me in tailoring your coaching program! All items/fields are required**

**Your name:

**and E-mail address:

**How long have you smoked?

**How much do you smoke a day?

**Check all the ways you've tried to quit smoking

    This is my first attempt

    Cold turkey

    Gradual reduction

    Zyban (Wellbutrin^®)

    Nicorette^® gum

    Patch

    Nicorette^® inhaler

    Nicorette^® lozenges

    Herbal pills

    Books, audio cassettes, videos etc

    Acupuncture

    Hypnosis

**Reasons you think they might have failed or other ways you've tried quitting

**What are the top 3 reasons you want to quit smoking? (1 = Most important; 2 = 2nd most important; 3 = 3rd most important)

    a) to improve my overall health and well-being

    b) my doctor has warned me about an existing smoking related illness

    c) to feel better about myself and improve my self-esteem

    d) I am just sick and tired of smoking

    e) I dislike being addicted to nicotine and want to change my life

    f) to fulfill a promise to loved ones

    g) to build a new image

    h) I'll succeed in quitting this time

    i) I'm not scared to quit smoking this time

    j) I have a positive attitude and I know I can beat this habit & addiction

    k) I am not going to procrastinate any more!

    l) I'm ready, regardless of what it takes!

    m) I am not going to make excuses or rationalizations any more

**My smoking has resulted in the following illnesses (check all that apply):

    a) Heart disease

    b) Bronchitis

    c) Emphysema

    d) General poor health

    e) Digestive problems

    f) High blood pressure

    g) Coughing with phlegm

    h) None at the moment

**What are your greatest concerns about quitting?

Do you have any other comments?:

e.g., why you want to quit smoking, your smoking habits, any other information you want to add.

Thank you for taking the time to complete your smoking history!