Smoking Cessation Screening 
Thank your for your interest in the Ceasewell Smoking Wellness Program. Please take the time to complete the initial pre-screening survey to assess your appropriateness for the program. 

Thank you for your interest in our program and the journey to a healthier lifestyle!
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Email *
First and Last Name  *
Date of Birth  *
MM
/
DD
/
YYYY
Gender  *
Ethnicity  *
Race  *
Do you smoke? *
What do you smoke? *
How long have you smoked? *
What age did you start smoking? *
Do you currently use any other drugs/substances? If so, what? *
Do you smoke within 30 minutes of waking up? *
How often do you smoke? *
Do you feel your smoking makes daily life tasks easier or more difficult? *
Do you find yourself unable to function until something is smoked? *
Does smoking impact you emotionally? If so, how? *
Does smoking impact you physically? If so, how? *
Does smoking impact you mentally? If so, how? *
Does smoking impact you financially?  *
How much would you say is spent on average per month surrounding smoking habits? (This includes purchase of materials for smoking) *

Have you experienced additional health complications due to smoking? (asthma, chronic bronchitis, etc) if so, what complications?

*

Have you ever felt a need to cut down or control smoking but had difficulty? 

*

Do you find yourself having negative emotions such as anger or sadness when called out about smoking?

*
How do you deal with stress? *
What is your current stress level on a scale of 1-5? (1 being not stressed at at to 5 being extremely stressed) *
Not stressed
Extremely stressed
Do you smoke more when stressed? *
Have you ever sought therapeutic methods to stop smoking? *
Are you open to using holistic remedies throughout this workshop to help cease smoking? (Meditation, yoga, etc) *
Would you prefer a virtual or in-person workshop? *
Please explain your reasoning for wanting to participate in a smoking cessation workshop.  *
Have you experienced trauma(s) over the course of your life?  *
What are you hoping to gain from this experience? *
Please list current medications being taken and dosage.  *
This workshop is a 5-week program, is that time frame something you feel you can be committed to? *
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