To better understand your condition and your readiness to quit smoking, your doctor may ask you some questions about your smoking habit. Complete this form and take it to your doctor.
| I smoke cigarettes a day | |
| I have been smoking for years | |
| This is the first time I have tried to quit | |
| I have tried to quit times in the past | |
| The methods I have used to quit are: | |
| Cold turkey (no treatments) | |
| Acupuncture | |
| Hypnotherapy | |
| Herbal or complementary treatments | |
| Nicotine replacement therapy, e.g. gum, patches, inhaler, lozenges, microtabs | |
| A prescription treatment from my doctor | |
Take this form to your doctor to help them provide you with the right advice.
