Smoking Cessation
Clinic
Diagnostic
Form
Smoking
Background
 

1. At what age did you first start to smoke ?  
 
2. What where the reasons for this initial experience ?
3. Which of your family members smokes ? 
4. How many serious attempts at quitting have you 

made since starting to smoke?
 
5. What methods did you use during these attempts ?
 
6. How many times have you managed to quit for

 a period of at least 3 month ? 
7. Which method did you use ?
8. What is the maximal period of time during which

 you completely avoided smoking ?
9. How many years have you been smoking, all in all ?
10. How long have you been smoking since 

your last attempt at stopping ?
11. How many cigarettes do you smoke per day since 

your last attempt at stopping smoking ?
12. What has caused you to fail in the past ?
13. In your own words, name 5 reasons for why you 

 smoke today, and what satisfaction do you receive from smoking ?
14. In your own words, name  5 reasons why would

you like to stop/quit smoking ?
15. Specify all medications  which you have 

recently been taking, and why do you take them ? 
16. Describe any health related problem you may be suffering from.
17. Describe any heart or blood related problem you may have.
18. Have you ever been through a heart attack ? If so, when ?
19. Has your heartbeat  ever been high or unstable ?
20. Have you ever experienced heart related chest pains ?
21. Do you have problems chewing or pain in the jaw ?
22. For women:
  a. Previous menstruation
 b. Current contraceptive
c. Are you due in the next 6 months ?
23. Will you be seeking personal guidance ?
24. Will you attend councelled support groups during the program ?
25. What form of physical activity do you prefer (if any) ?
26. Do you have difficulty breathing or and other form 

of discomfort during any kind of activity?
27. Name of  Doctor : 
     Doctor's address:
28. Date of previous physical chek-up: 

All information of this document has been given to the best of 
my ability and I hereby declare that it is the  truth.
Signature:     Date : 

     

     

    Frequently Asked Questions:

    Q: Can smoker really receive the full treatment in only one clinic visit ?
    A: Definitely !

    Q: Are the substances which constitute the medication approved 
    by the United States Food and Drug Administration?
    A: Yes. The medication was approved years ago.

    Q: What are the success percentages ? 
    A: Success has be noted at 80%-90% after 1 month.

    Q: How many people have been treated in this method so far ?
    A: In the United States over 50,000 people have received this 
    treatment so far. In Israel 50 subjets a week receive this treatment.

    Q: Can anyone receive the Smoke Out treatment ?
    A: No, those suffering from the following health disorders 
    cannot receive the treatment:
    1 . Enlarged prostate with urinary retention.
    2 . Elevated internal eye pressure (Glaucoma).
    3 . Severe high unstable blood pressure. 
    4 . Pregnancy.
    5 . Epilepsy.
    6 . Severe mental disorders.
    7 . Severe ? heart disease.
    8 . Arrhythmias.


    Adiction Analysis Questionnaire
    Symptoms of Addiction:
    1 . Craving from nicotine.
    2 . Nervousness, frustration, anger. 
    3 . Anxiety. 
    4 . Luck of concentration. 
    5 . Restlessness.
    6 . Slowing heartrate. 
    7 . Increase in appetite, weightgain. 
    Please answer the following questions to enable

    the diagnosis of your addiction score:
    1 . After waking up, when do you light

    your first cigarette?
    a. Within 30 minute.
    b. After 30 minutes.     		 score

    1
    0
    2. Do you find it difficult not to smoke 

    in a non smoking area? 
    a . yes.
    b.no    		 score

    1
    0
    3 . Which of the cigarettes you smoke during the day 
    is the most pleasuring?
    a . The first one in the morning?
    b . Any cigarette.    		 score

    1
    0
    4 . How many cigarettes do you smoke during the day ?
    a . 1-10 cig. (light smoker).
    b . 11-25 cig. (medium smoker).
    c . 25 cig. and more (heavy smoker).    		 score

    0
    1
    2
    5 . Do you smoke more in the morning 
    than any other time of the day ?
    a . yes 
    b . no    		 score

    1
    0
    6 . Do you smoke also when you
    are ill and stay in bed ?
    a . yes 
    b . no    		 score

    1
    0
    7 . What is the tar/nicotine level stated on the 
    pack of cigarettes you smoke ?
    a . low, 1-8 mgm/ccm.
    b . moderate, 9-15 mgm/ccm.
    c . high, 15 mgm/ccm and above.    		 score

    0
    1
    2
    8. How often do you inhale the smoke ? 
    a . every now and then.
    b . frequently.
    c . continuously.    		 score

    0
    1
    2

    Total personal score 1,2,3,4,5,6,7,8,910,11

    Maximal score is 11. Dependency increases the higher the score
    

    



Name:     Last Name:   
    P.O.B:    Street:    
    City:     Zip:       
    Country:  State:     
    Fax Num:  Phone Num:  
    Date of Birth:
 [Home Page] [About] [Diagnostic Form]

Smoking Cessation Clinic
Tel Aviv, Israel. 
Tel: 972 50 5954448
Email: Smokeout@netguide.co.il
Copyright 1997 © All rights reserved to Smoke Out and Doryanet