Smoking Cessation Assessment Form

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New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.

Please take a few minutes to answer the following questions so that we can determine the best methods to help you. You will be contacted by UHCS to schedule an appointment after submitting this form. Feel free to contact us if you have not heard back in a week. Your answers are confidential. UHCS is located in the Forysth building and can be reached at (617) 373-2772 (option 1). Thank you

Last Name *

First Name *

M.I.

NU ID *

Cell Phone No *

Northeastern Email address (@northeastern.edu) *

Select ONE that best describes you *

I am using tobacco and thinking about quitting

I am using tobacco and ready to quit

I quit using tobacco less than three weeks ago

I quit using tobacco three or more weeks ago

How did you learn about RTQ? (select all that apply) *

Were RTQ ambassadors helpful? *

Yes

No

Not applicable, I did not interact with a RTQ ambassador

Please describe how RTQ ambassadors were helpful *

Please describe how RTQ ambassadors were NOT helpful *

Were RTQ ambassadors informative? *

Yes

No

Not applicable, I did not interact with a RTQ ambassador

Please describe how RTQ ambassadors were informative *

Please describe how RTQ ambassadors were NOT informative *

Current number of cigarettes/nicotine per day *

Age started? *

No. of years smoking? *

Select all tobacco/nicotine products you use *

Do you smoke within 30 minutes of waking up? *

Yes

No

Have you tried to quit in the past? *

Yes

No

Number of quit attempts *

How recently did you try to quit? *

How did you try to quit? (select all that apply) *

Since you started smoking, what is the longest you've gone without tobacco? *

Are you using any other recreational substances e.g alcohol, marijuana, etc.? *

Yes

No

Please list the recreational substances you are using e.g alcohol, marijuana, etc. *

How much and often do you use the recreational substance you have listed above? (e.g. daily, weekly, monthly, two beers, four shots, etc.) *

Are there any other health concerns you may have?

List all medications, herbs, supplements you are currently taking

Reason(s) for quitting now? *