We have been providing smoking cessation counseling for one year now and we are evaluating our program. We are interested in how successful the smoking cessation program has been for patients in helping them quit smoking. The answers will be pooled with no identifying information. Thank you for your time.

Sincerely, Kathryn Flanigan, NP for the Centre for Family Medicine

* 1. Who did you see for counseling?

* 2. Did you have a follow up appointment?

* 3. If you answered yes... with whom did you have a follow up appointment?

* 4. If you answered no... why not?

* 5. Did you use any smoking cessation aids? Check all that apply.

* 6. Did you quit smoking? If you answered yes... for how long?

* 7. If not, did you cut down smoking? How much?

* 8. Did anyone in your family quit smoking with you?

* 9. If you did not quit smoking, do you want to make another appointment to try again? If not, why?

* 10. What did you find most helpful in the counseling sessions? What could we do to improve the program? Do you have any further comments?