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K'aute Pasifika Services
Smokefree Service
COVID-19 Self-isolation Form
Pacific Smokefree Services Form
Smokefree services referral form
Congratulations for taking the first step in becoming Smokefree! We offer free one-on-one support. Please complete this form and our Smokefree coach will contact you.
Personal Details
Title
*
Select one...
Mr
Mrs
Miss
Ms
First Name
*
Last Name
*
Ethnicity
*
D.O.B
*
Gender
*
Select one...
Male
Female
Email
*
Home Ph
Other Ph/Mobile
Street Address
*
Suburb
*
Town/City
*
Post code:
*
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NZPost Postcode Finder
NHI Number
Contact Details
Next of Kin
Next of Kin Phone
Next of Kin Address
Doctor/Midwife (name)
Doctor/Midwife Address/Contact
Doctor/Midwife Phone
Questions about your smoking
How many cigarettes do you usually smoke each day?
How many of these are hand-rolled cigarettes?
Have you recently cut down?
Select one...
Yes
No
If yes, how many cigarettes per day did you use to smoke?
How much money are you spending on tobacco per week?
How soon after waking up do you usually smoke?
Select one...
Within 5 mins
6-30 mins
31-60 mins
After 1 hour
Does your spouse or partner smoke?
Select one...
Yes
No
No spouse/partner
What is the longest time you’ve succeeded in giving up smoking in the last 3 years?
Select one...
Few hours
1 day
2-3 days
4-7 days
1-3 weeks
1-3 months
More than 3 months
Not tried
How long ago was your last serious attempt to stop?
Select one...
1-3 weeks
1-6 months
More than 6 months
More than a year
Never tried before
What was the ONE MAIN THING that led you back to smoking last time?
Select one...
Never stopped before
Got too miserable
Craved too much
Put on too much weight
Got too bad tempered
Got too stressed
Thought I could smoke and stop easily
Cannabis smoking
Getting drunk
Other
If other, please give us details
What is your ONE MAIN REASON for wanting to stop now?
Select one...
To save money
To stop being addicted
To protect my health
To please others
It’s anti-social
Other
If other, please give us details
Are you any of the following
Select one...
Pregnant
Trying to conceive
Breast Feeding
None of these
I am a Male
About how many cigarettes did you smoke per day in the last week?
How much of the time have you felt the urge to smoke in the last week?
Select one...
Not at all
A little of the time
Some of the time
A lot of the time
Almost all of the time
All of the time
Smokefree Environments
Home:
Select one...
Allowed inside the home
Not allowed inside the home
Car:
Select one...
Allowed inside the car
Not allowed inside the car
Do not have a car
Please show for each of the symptoms below how you have been feeling over the past week
Low mood:
Select one...
Not at all
Slightly
Somewhat
Very
Extremely
Irritable, Angry, Grumpy:
Select one...
Not at all
Slightly
Somewhat
Very
Extremely
Restless, Can’t sit still:
Select one...
Not at all
Slightly
Somewhat
Very
Extremely
More hungry than normal
Select one...
Not at all
Slightly
Somewhat
Very
Extremely
Can’t concentrate
Select one...
Not at all
Slightly
Somewhat
Very
Extremely
Slept worse than usual
Select one...
Not at all
Slightly
Somewhat
Very
Extremely
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