Please fill in the form below and then press the "Send" button. An officer from the
Department of Health Promotion will contact you about your application as soon as possible.
Do not press the Enter key as this will cause the form to be submitted prematurely.

1.  Do you believe that someone can help you to stop smoking? Yes No

2.  How old were you when you started smoking?  years

3.  How many cigarettes do you smoke daily?  

4.  Do you smoke: (choose one or more)
     Cigarettes (filtered)
     Cigarettes (not filtered)
     Cigars
     Pipe

5.  What brand of cigarettes do you smoke?

6.  How dependent do you feel on cigarettes / cigars / pipe?
     A lot Not so much Not at all

7.  Do you smoke before breakfast?
     Yes No

8.  When and where do you feel you need to smoke most?

9.   How often have you tried to stop?
      Never Once or twice Several times

10. When you quit smoking how healthier do you think you will be?
      Much healthier A little healthier No difference

11. Do you think that in a year's time you would start smoking again?
      Yes No

12. Which Health Centre would you prefer to attend?