Tobacco Screen (GI) Question Title * 1. Contact Information Name Date of Birth Location Today's Date OK Question Title * 2. Have you used any form of tobacco in the past six months? Yes No (Thank you for your time. You do not need to complete the rest of this form.) OK Question Title * 3. Please check the box beside the statement that best matches your current goals: I have quit within the past 6 months I am planning to quit in the next month I am planning to quit in the next 6 months I am not planning to quit I would like to cut back OK Question Title * 4. How old were you when you became a daily smoker? OK Question Title * 5. How many years have you used tobacco? OK Question Title * 6. What form of tobacco do you currently use? Cigarettes Cigar Pipe Chew OK Question Title * 7. How many cigarettes do you smoke each day? 10 or fewer 11-20 21-30 31 or more OK Question Title * 8. How soon after you wake up do you smoke your first cigarette? Within 5 minutes 5-30 minutes 31-60 minutes After 60 minutes OK Question Title * 9. When did you last try to quit smoking? Never tried to quit (skip to question #14) Within the last month Within the last year Over 1 year ago Over 5 years ago OK Question Title * 10. Why did you stop last time? OK Question Title * 11. How long did you go without smoking that time? OK Question Title * 12. Why did you start smoking again? OK Question Title * 13. Which method(s) have you tried? Nicotine Patch Cold Turkey Nicotine Gum Chantix Other (please specify) OK Question Title * 14. Feelings about changing your tobacco use. Answer the following three questions with respect to the goal you set in Section B: Not at all Important Very Important How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? Not at all Important How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? How important is it for you to change your tobacco use? Very Important How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? Not at all Important How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? How confident are your that you could change your tobacco use? Very Important How ready are you to change? How ready are you to change? Not at all Important How ready are you to change? How ready are you to change? How ready are you to change? How ready are you to change? How ready are you to change? How ready are you to change? How ready are you to change? How ready are you to change? How ready are you to change? Very Important OK Question Title * 15. If you continue to use tobacco what POSITIVE benefits do you get from your usage? OK Question Title * 16. If you continue to use tobacco what NEGATIVE harm or NEGATIVE effects has your tobacco use caused you? OK Question Title * 17. Why do you want to change your tobacco use? OK Question Title * 18. What would you gain by changing your tobacco use? OK Question Title * 19. What would be hard about changing your tobacco use? OK Question Title * 20. What concerns do you have about changing your tobacco use? OK Question Title * 21. Do you or other people smoke inside your home? Yes No OK Question Title * 22. Do you or other people smoke inside your car? Yes No OK Question Title * 23. Among your friends, family, and co-workers what percentage would you say smoke? Almost none About half Most OK Question Title * 24. How much do you drink of the following caffeinated drinks per day? Regular Coffee (8 oz) Tea (Bags) Soda (12 oz) What is the amount you drink daily of each? OK Question Title * 25. Have you ever felt you should cut down on your alcohol consumption? Yes No OK Question Title * 26. Have people annoyed you by criticizing your alcohol consumption? Yes No OK Question Title * 27. Have you ever felt bad or guilty about your alcohol consumption? Yes No OK Question Title * 28. Have you ever had a alcoholic beverage first thing in the morning to steady your nerves or get rid of a hangover? Yes No OK Question Title * 29. Do you use any of the following drugs? (Check all that apply.) Cannabis (marijuana, hash, pot) Amphetamines/Stimulants Barbiturates Hallucinogens Cocaine/Crack Benzodiazepines Heroin/Opium Other (please specify) OK Question Title * 30. Does your drug benefit plan cover quit smoking medications? Yes No Do Not Know No Benefit Plan OK DONE
