Smoking Questionnaire

Stacey Petticrew


     

     

Name: 


A red asterisk (*) indicates required questions.

  1. Please state your gender:*
    Female
    Male


  1. What age are you?*
    16
    17
    18


  1. Have you smoked in the last two years?*
    Yes
    No


  1. Are you a smoker now?*
    Yes
    No


  1. Tick the box which you think most reflects your smoking habits:*
    once per day
    2 - 4 cigerettes per day
    5 - 7 cigerettes per day
    8 - 10 cigerettes per day
    10 - 15 cigerettes per day
    15 - 20 cigerettes per day.
    More than 20 per day
    I don't smoke.


  1. What age do you think you will be when you give up smoking?*
    17
    18
    19
    20
    21 - 25
    25 - 30
    30 - 40
    40 - 45
    over 45
    never
    I don't smoke.


  1. Have you ever tried to give up smoking?*
    Yes
    No
    I don't smoke.


  1. Compared to other boys and girls your age how likely do you think you are to get lung cancer?*
    Less likely
    about the same
    more likely


  1. Compared to other boys and girls your age how likely do you think you are to be hooked on cigerettes when you are twenty?*
    less likely
    about the same
    more likely


  1. Compared to other boys and girls your age how often do you think you get coughs and colds.*
    less often
    about the same
    more often.


  1. Compared to other boys and girls your age how out of breath do you get when you run around?*
    less out of breath
    about the same
    more out of breath


  1. Compared to other boys and girls your age how fit do you think you are?*
    less fit
    about the same
    more fit


  1. What is the legal age to buy cigarettes and smoke in Northern Ireland?*
    15 if for someone else
    16
    17
    18


  1. Tick the following places that are ILLEGAL (against the law) to smoke in.*
    Bars and Clubs
    Hospitals
    The Bus
    Cafes
    Taxi
    Work Van
    Own Car
    Schools
    School Playground
    Own House
    Dentist
    Shopping Centre
    Private Clubs
    On the street
    On an Aeroplane
    Cinema
    Beach


  1. Please click the statement that's most true for you.



    Smoking makes you look grown up?*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smoking can help to calm you down.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smoking gives you confidence.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smoking can put you in a better mood.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smoking can help you stay slim.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smoking can help you make friends more easily.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smokers have more fun than people who don't smoke.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smokers are more likely to have boyfriends or girlfriends than people who don't smoke.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smokers are more boring than people who don't smoke.*
     
      1 2 3     Don't Know
    Agree  Disagree  


  1. Smokers tend to break more rules than non smokers.*
     
      1 2 3     Don't Know
    Agree  Disagree  





Mrs Ennis