Reflective Q's | I Choose To Smoke 1.O

top of page

Behavioural Change

Through

Behavioural Awareness

I Choose To Smoke

Home
About
Contact
More

Use tab to navigate through the menu items.

Reflective Questionnaire

Before we speak, please take a few minutes to answer the questions below. There are no 'right' answers - only honest ones.

First name*

Last name*

Email*

How many cigarettes do you currently smoke per day? *

Fewer than 5

5-10

10-15

15-20

20-25

More than 25

How long have you been smoking?*

Less than 1 year

1-5 years

5-10 years

10-20 years

20+ years

First cigarette timing *

Within 5 minutes of waking

Within 15 minutes

Within 30 minutes

After 30 minutes

Option 5

Previous attempts *

No

Yes - once

Yes - 2-3 times

Yes - more than 3 times

You're welcome to answer in as much detail as you like here;

What would you most like to be different about your smoking over the next few weeks?

Is there anything else you would like to share before we speak?

Contact | Terms of Service | Privacy Policy | Disclaimer

© 2026 by I Choose To Smoke. All rights reserved.

bottom of page