Address 

City
 Province/State 

Postal Code/Zip 
 Email 

Phone (H/W) 
 Cell 

Birth Date 
 (YYYY/MM/DD)
Physician 

Phone # 

Address 
How many cigarettes per day are you currently smoking? 

How old were you when you first started smoking? 

How many times have you attempted to quit smoking? 

What is the longest amount of time you have been without smoking? 

Do other members of your family smoke? 
 Yes / 
 No
Are you recovering from any other addictions? 

Which?

Are you using other substances that are causing problems in your life? 

If so, which?
Do you have any medical conditions requiring medical supervision? 
 Yes / 
 No

If so, which?
Are you taking medication? 
 Yes / 
 No

If so, what?
Are you under psychiatric care? 
 Yes / 
 No

If so, who is your Doctor? 

Phone # 

Do you consent to your Tobacco Addiction Counsellor consulting with your Physician if necessary? 
 Yes / 
 No
Have you used Nicotine Replacement? (Patch/Gum/Inhaler) 
 Yes / 
 No

If so, what and when? 

What was your experience with Nicotine Replacement?

Do you intend to use any of these supports during the program?
What are your core reasons for wanting to be smoke-free?
Can you identify one person who you can rely on and trust to help you through this process for at least 180 days? 
How old were you when you started smoking? 

How long after rising do you need a smoke? 

How many cigarettes do you smoke on a bad day? 
How would you like us to contact your after we have reviewed your assessment? (Email or phone, time(s) you are available?)