Please answer each of the following items as they apply to you by simply encircling the

letter of your answer of your answer. Answer as honestly as you can.

SLEEP HABITS

1. Do you generally follow a regular sleep cycle-same bedtime and waking time?

a. Yes b. No

2. Do you have trouble falling asleep or staying asleep?

a. Yes b. No

3. Do you drink caffeinated beverages at night?

a. If yes, how many cups? ______

b. No

4. Do you eat before going to sleep?

a. Yes b. No

5. Do you drink alcohol or liquors in the evening?

a. If yes, how many bottle? ________

b. No

6. What time do you usually go to bed?

a. 8 pm

b. 9 pm

c. 10 pm

d. 11 pm

e. 12 am

f. 1 am

7. How much sleep do you usually get per night?

a. 1 to 4 hours

b. 5 to 7 hours

c. 8 to 1o hours

EATING HABITS

1. Do you eat every 2 to 3 hours throughout the day?

a. Yes b. No c. Sometimes

2. Do you eat a variety of foods each day?

a. Yes b. No c. Sometimes

3. Do you usually eat the following foods on a daily basis (on average)?

7 – 8 servings of fruits and vegetables a. Yes b. No c. Sometimes

6 – 8 servings of grain products a. Yes b. No c. Sometimes

2 – 3 servings of milk or alternatives a. Yes b. No c. Sometimes

2 – 3 servings of meat, fish or alternatives a. Yes b. No c. Sometimes

4. Do you usually eat junk foods?

a. If yes, how often? __________

b. No

5. Do you usually eat high fat foods?

a. If yes, how often? _____________

b. No

6. How much glasses of water do you drink throughout the day?

a. 6 glasses of water

b. 8 glasses of water

c. 10 glasses and more

7. How many cups of coffee do you drink throughout the day?

a. Less than 3 cups

b. More than 4 cups but not greater than 6 cups

c. More than 6 cups

8. How many cups of rice can you consume per day?

a. 3 cups of rice

b. More than 4 cups but not greater than 6 cups

c. More than 6 cups but not greater than 10 cups

PHYSICAL ACTIVITY

1. Do you engage in moderate physical activity 4 to 5 times per week?

a. Yes b. No c. Sometimes

2. Do you enjoy being physically active?

A. Yes b. No c. sometimes

3. What keeps you from being more active? (Example: possibility of losing weight,

sharing it with a friend, how I feel afterwards)

_____________________________________________________

_____________________________________________________

4. What motivates you to be more active?

_____________________________________________________

_____________________________________________________

5. What types of activities have you enjoyed in the past?

_____________________________________________________

_____________________________________________________

ALCOHOL CONSUMPTION

1. How often do you have a drink containing alcohol?

0) Never (skip to questions 9 & 10)

1) Monthly or less

2) 2 – 4 x per month

3) 2 – 3 x per week

4) 4+ x per week

2. How many drinks containing alcohol do you have on a typical day when you are drinking?

0) 1 – 2 2) 3 – 4 3) 5 – 6 4) 7, 8 or 9 5) 10 and above

3. How often do you have 6+ drinks on one occasion?

0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or

almost daily

4. How often during the last year have you found that you were not able to stop drinking once

you had started?

0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or

almost daily

5. How often during the last year have you failed to do what was normally expected from you

because of drinking?

0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or

almost daily

6 How often during the last year have you needed a drink in the morning to get yourself going

after a heavy drinking session?

0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or

almost daily

7 How often during the last year have you had a feeling of guilt or remorse after drinking?

0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or

almost daily

8 How often during the last year have you been unable to remember what happened the night

before because you had been drinking?

0) Never 1) Less than monthly 2) Monthly 3) Weekly 4) Daily or

almost daily

SMOKING HABITS

1. How long have you smoked regularly?

[1] Less than 2 years

[2] 2–3 years

[3] 3–4 years

[4] 4–5 years

[5] 5 or more years

2. On average, how many cigarettes per day do you currently smoke?

[1] Less than 10 cigarettes

[2] 10–19 cigarettes

[3] 20 or more cigarettes

3. Age you started smoking?

[1] Under 20 years

[2] 20–29 years

[3] 30 years and older

4. Have you ever made an attempt to stop smoking?

[1] Yes (Continue)

[2] No (Skip to Question 18)

5. How many times have you ever tried to stop smoking?

[1] 1 time

[2] 2 times

[3] 3 times

[4] 4 times

[5] 5 times

[6] 6 times and over

STRESS MANAGEMENT

1. On a scale of 1 to 10 (1 = low stress, 10 = high stress) where are you right now? Pls. put a

check mark

1____2____3____4____5____6____7____8____9____10

2 When you are not in work, where are you on the stress scale? Pls. put a check mark

1____2____3____4____5____6____7____8____9____10

3. How does stress affect you? (Circle all that apply)

a. worry all the time

b. increased irritability

c. difficulty sleeping (can’t get to sleep / stay asleep)

d. sleep all the time

e. exhaustion

f. withdraw socially

g. difficulty concentrating

h. loss of appetite

i. become depressed

j. feel anxious

k. feel panicked

l. feel tense – physically uncomfortable

m. increased restlessness or agitation

n. have no energy or motivation

4. What helps you reduce the negative effects of stress?

______________________________________________________________________________

5. How often do you try to do this in a week?

______________________________________________________________________________

6. Are you aware that the how you eat, sleep, exercise, and manage your time can increase or

decrease your stress levels? a. Yes b. No

7. Do you feel satisfied with your social life? (Friendships, connections) a. Yes b. No

8. Do you feel satisfied with your spiritual life? a. Yes b. No

9. What stress management strategies do you use on a regular basis?

________________________________________________________________________

6. On your most recent quit attempt, how long were you able to stop smoking?

(“√” one answer)

[1] < 1 week

[2] 1–2 weeks

[3]2–3 weeks

[4] 3 weeks – 1 month

[5] 1–2 months

[6] 2–3 months

[7] 3–4 months

[8] 4–5 months

[9] 5–6 months

[10] 6 or more months

7. Your reasons for trying to stop smoking? (“√” more than one answer)

[1] Family pressure

[2] Health concern (for self and family members)

[3] Advice and example from others

[4] Cost

[5] Restrictions on smoking in workplace, on public transportation, at

home

[6] Social stigma

[7] Other (please specify)

8. Method most often used to quit smoking?

[1] Will power

[2] Behavior approach (stay away from smokers, distract, drink tea and so

on)

[3] Medical measures (like nicotine replacement, Chinese traditional

medicine)

[4] Family help

[5] Commercial cessation products

[6] Other (please specify)

9. In the above which method do you think was the most effective? ________

TIME MANAGEMENT

1. Do you have enough time to accomplish all that you need to do?

I. Often II. Not Often III. Never

2. Do you set realistic goals each day?

I. Often II. Not Often III. Never

4. Do you make a list each day of the tasks you want and need to do?

I. Often II. Not Often III. Never

5. Do you set priorities each day and identify tasks that must be done, tasks that may be done and

tasks that can be put off?

I. Often II. Not Often III. Never

6. Do you have a weekly plan that allows time for work, recreation, social and other activities

(creative outlets, job, clubs, volunteer work)

I. Often II. Not Often III. Never

Please check all the diseases that applies to you.

Asthma

Hypertension

Pneumonia

Diabetes

Arthritis

Colds

Cough

And if none of the above, please specify the disease you had before ___________________.

10. Most influential trigger to smoke when you tried to quit smoking? (“√” one

answer)

[1] In social situations (e.g., in the company of other smokers, etc)

[2] When feeling stressed

[3] When feeling negative, or down

[4] When feeling positive, or elated

[5] During entertainment (playing cards for money, playing Majiang,

watching sport, etc)

[6] While reading or writing

[7] When alone

[8] In the presence of alcohol

[9] After a meal

[10] When feeling tired

[11] Other (please specify)

11. The most influential situation that caused your relapse? (“√” one answer)

[1] In social situations (e.g., in the company of other smokers, etc)

[2] When feeling stressed

[3] When feeling negative, or down

[4] When feeling positive, or elated

[5] During entertainment (playing cards for money, playing Majiang,

watching sport, etc)

[6] While reading or writing

[7] When alone

[8] In the presence of alcohol

[9] After a meal

[10] When feeling tired

[11] Other (please specify)

12 Which one most caused your relapse?

[1] Low self- control

[2] The influence of other smokers

[3] A lack of available cessation methods

[4] Little family support

[5] Other (please specify)

13. Do you want to quit smoking?

[1] Don’t want to quit

[2] Want to attempt to quit smoking

[3] Strong desire to quit smoking

14. If you try to quit smoking, how would you describe your self-confidence in successfully

quitting smoking?

(“√” one answer)

[1] Will be successful

[2] May be successful

[3] May succeed or fail

[4] Likely to fail