Lifestyle questionnaire - IRCM

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4- Medication sectionVHere is a list of questions that is intended to evaluate your lifestyle.For each of them, check off the answer that best reflects your current lifestyle:QUESTIONSNEVERASOMETIMESBOFTENCALWAYSDI forget to take my drugs 58The drugs I take must be causing some side effects 59I think I am taking too many drugs 41, 60TOOLSDO YOU TAKE YOUR DRUGS AS PRESCRIBED BY YOUR DOCTOR?A. YES, for over 6 months MaintenanceB. YES, for less than 6 months ActionC. NO, but I plan to start doing so within the next 60 days PreparationD. NO, but I plan to within the next 6 months ContemplationE. NO, and I do NOT plan to within the next 6 months PrecontemplationF. F. My doctor has not prescribed any drugs for me Not applicable
5- moking sectionThis <strong>questionnaire</strong> is intended for EVERYONE. Please answer these questions.For question 1, start with the column that corresponds to your situation and only answer the questionsin this column.QUESTION : How would you describe your smoking experience at present? TOOL 61I smoke every day(1)I smoke but not every day(2)I don’t smoke but I used tosmoke every day(3)I don’t smoke but I havesmoked occasionally(4)I have never smoked(5)How many cigarettesdo you smoke per day?How many cigarettes doyou smoke per week?How many cigarettes didyou smoke per day?How many cigarettes didyou smoke per week?SKIP THIS SECTION________________________________________________________________________Do you smoke filtercigarettes?How old were you whenyou started smoking?How old were you whenyou started smoking?How old were you whenyou started smoking?Yes No_________ years old_________years old_________years oldHow old were youwhen you startedsmoking?_________ years oldHow old were you whenyou stopped smoking?_________years oldHow old were you whenyou stopped smoking?_________years oldHAVE YOU STOPPED SMOKING?A. YES, for over 6 months (go to question 19) MaintenanceB. YES, for less than 6 months (go to question 19) ActionC. NO, but I plan to start doing so within the next 60 days PreparationD. NO, but I plan to within the next 6 months ContemplationE. NO, and I do NOT plan to within the next 6 months PrecontemplationF. I have never smoked cigarettes (go to question 19) Not applicableDO YOU CURRENTLY SMOKE A PIPE?YES, every day (1)YES, sometimes (2)NO (3)TOOL 61WHEN DID YOU TAKE YOUR LAST PUFF?________DAYS_______MONTHSASIDE FROM YOU, HOW MANY PEOPLE SMOKE AT HOME?_______PERSONNESDO YOU CURRENTLY SMOKE CIGARS?YES, every day (1)YES, sometimes (2)NO (3)TOOL 61DO YOU CURRENTLY USE CHEWING TOBACCO OR SNUFF?YES, every day (1)YES, sometimes (2)TOOL 61NO (3)ARE YOU CURRENTLY ON SMOKING CESSATION MEDICATION?YES NO WHAT KIND? Skin patches Nicotine gum Zyban (bupropion)OVER THE PAST TWO YEARS, HOW MANY TIMES HAVE YOUTRIED, SUCCESSFULLY OR NOT, TO STOP SMOKING?________ TIMESWHEN DID YOU FINISH YOUR LAST CIGARETTE?________DAYS_______MONTHS
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Lifestyle questionnaire - IRCM

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