Personal Wellness Assessment Thanks for taking our survey. Before we can create your custom plan, we need to ask you a few questions. Let’s get started. Current Page 1 of 3 Page 2 of 3 Page 3 of 3 Complete Name 1. How many cigarettes do you typically smoke per day? (1 pack = 20 cigarettes) 1-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41 or more 2. How many times have you tried to quit smoking? 0 times 1-2 times 3 or more times 3. Smoking relaxes me and gives me pleasure. True Not true 4. I tend to smoke when I get angry, irritated, sad, or worried. True Not true 5. When I haven’t smoked for a while, I get a real craving for a cigarette. True Not true 6. I can smoke without even knowing I’m doing it. True Not true How important to you are each of the following reasons for quitting smoking? 7. Being healthy, preventing illness, or living longer: Very important Not important 8. Being a better role model for my kids or others: Very important Not important
Personal Wellness Assessment Thanks for taking our survey. Before we can create your custom plan, we need to ask you a few questions. Let’s get started.
