Group Registration details

NTMI Participant Registration Details

Staff to transfer hard copy data to this form
1. Course ID number:
2. Course location:
3. Participant ID # (initials, course number, birth year. ie DG179)
4. date Of Birth:
5. Gender
6. How Many cigarettes do you smoke each day?
7. How many years have you been smoking?
8. Participation goals. Would you like to:
9. Have you ever tried to quit before?
10. What is the longest you have gone without smoking?
11. What are your main reasons for wanting to quit/cut back?
12. Have you been to any other tobacco related support groups previously? Was it a NTMI group?
13. Are you currently participating/involved with any other mental health organisation(s) or support groups? if so which ones?
14. Permission to send to Dr or Support worker
15. Living arrangements
16. Do you live with other smokers
17. What is your primary mental health diagnosis?
18. Please feel free to list any secondary mental health diagnosis?
19. Have you been hospitalised due to your mental illness within the past 12 months?
20. Do you have any of the following health problems?
21. Fagerstrom Score.
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