Questionnaire for Smoking Cessation Clinic (First visit)
Please measure your blood pressure after filling out the questionnaire sheet. Submit the sheet to the physician during yourconsultation.
Q1. Do you currently smoke?
□ Yes□ I quit smoking (□ I do not smoke

years ago/months ago)

If “Yes”, please answer the following questions.
Q2. On average, how many cigarettes do you smoke in a day?

sticks/day

Q3. How long has it been since you started smoking habitually?

years

Q4. Have you ever tried to quit smoking in the past?

NO / YES (Q5. What is the longest period that you have gone without smoking?

time/s)day/sQ6. Why did you decide to visit our smoking cessation clinic?
(check all that apply)□ Damaged your health; felt sick
□ You thought it’s not good for your future health□ Economic reasons□ Recommendation from family or acquaintance□ Advice from your physician□ It disturbs other people□ Lowering social acceptability of smoking)□ Others (Q7. Are you currently undergoing treatment or have been treated for the following diseases? (check if applicable)□ High blood pressure□ Diabetes□ Angina□ Cardiac Infarction□ Arrhythmia□ Cerebral stroke (hemorrhage, cerebral infarction)□ Hyperlipidemia (cholesterol, neutral fat)
□ Chronic bronchitis□ Bronchial asthma □ Emphysema□ Lung fibrosis (interstitial pneumonia)□ Tuberculosis, Gastroduodenal ulcer□ Gastritis□ Cancer, Malignant Tumor (Body part:)□ Others ()Q8. Is there anyone in your household that smokes?

YES / NO
relationship ()〒100-0004 東京都千代田区大手町一丁目 9 番 7 号 大手町フィナンシャルシティ サウスタワー2 階
Tel. 03-3527-9520 Fax. 03-3281-5630
Copyright © St. Luke's MediLocus All rights reserved.

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Q9. Occupation ()Q10. Do you work in a non-smoking office?
YES / NO (We have a separated smoking rooms / Smoking is allowed)
Q11. Your current height () cm

Weight () Kg

Q12. Please answer the below regarding your mental state.
(1) Please circle the below number that best averages how difficult the past week has been for you.

Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely(2) To what extent did that difficulty affect your daily life?

Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely
Q13. Read the questions below and put a circle to the applicable answer.
Questions

YES (1 point)

1

Do you have experience smoking more than you initially intended?

2

Have you ever failed when you tried to quit smoking or decrease the amountof cigarettes?

3

Have you ever craved to smoke when you tried to quit smoking or decrease
the amount of cigarettes?

4

Have you ever experienced any of the symptoms below when you tried toquit smoking or decrease the amount of cigarettes?
(Frustration, Nervousness, Restlessness, Distracted, melancholic, Headache,
Sleepiness, Upset stomach, Slow pulse, Shaky hands, Increase in appetite orweight)

5

Have you ever started smoking again to relieve the symptoms in Q4?

6

Have you ever smoked even after knowing you have a heavy disease and it is
not good for you?

7

Have you ever smoked knowing you have health problems caused bysmoking?

8

Have you ever smoked knowing you have a mental problem caused bysmoking?

9

Have you ever felt that you are addicted to smoking?

10

Have you ever avoided a job or a social obligation where you cannot smoke?

No (0 point)

Total
2022.2.1-Ver.3.00-A4 白黒両面
〒100-0004 東京都千代田区大手町一丁目 9 番 7 号 大手町フィナンシャルシティ サウスタワー2 階
Tel. 03-3527-9520 Fax. 03-3281-5630
Copyright © St. Luke's MediLocus All rights reserved.

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