Tobacco Assessment Form

Name:

Date:

1. Are you currently using tobacco products:

Yes No

2. What form of Tobacco?

3. Does the person closest to you use tobacco?

Yes No

4. How many cigarettes do you smoke a day?

5. How soon after you wake up do you use tobacco products?

within 30 minutes more than 30 minutes

6. How interested are you in stopping use of tobacco?

Not at all A little Some A lot Very

7. If you decide to quit the use of tobacco completely during the next two weeks, how confident are you that you would succeed?

Not at all A little Some A lot Very