Quit readiness assessment

Full Name

E-mail

Phone Number

1. How often do imagine yourself as a non-smoker ?

Daily
Weekly
Monthly
Rarely

2. How concerned are you about the effects of smoking on your general health?

Extremely worried
It often plays on your mind
Only when I'm sick
It's not a high priority

3. How do you handle stress in your daily life?

Regular exercise and meditation
Talking to friends or family
Engaging in hobbies or relaxation
Struggling to manage it
Smoking is my 'go-to

5. How committed are you to making positive changes in your life?

Highly committed
Somewhat committed
Neutral
Not committed at all

These questions can help me understand your current state and identify areas for improvement in their personal development and health journey.