Here’s the initial “quit nicotine” questionnaire we ask you to fill out when we provide coaching support. Often we work like they do in a “flipped classroom.” We ask you to do exercises when you’re not in session, and during our sessions we do the work. With this questionnaire we ask that you become intimate with the part of you that smokes.

1. When did you start smoking and why?

2. How many cigarettes a day do you smoke?

3. How have you tried to quit in the past?

4. Who else in your family smokes?

5. Which cigarette is your favorite cigarette of the day?

6. In previous quits, what worked and why did you relapse?

7. What will you miss most about smoking?

8. What won’t you miss about smoking?

9. What tells you that you’re ready to stop now? Why this particular time?

10. What do you see as the downside to quitting?

11. What do you see as the upside to quitting?

12. When you close your eyes and imagine yourself smoking, where are you?

13. If anything were going to get you to give up on your quit, what would those reasons be?

14. Imagine yourself as a nonsmoker. What do you see? Smell? Taste? Hear? Feel?

Printout of this exercise. The printout only leaves a couple of lines for each question which may not be enough space. If that’s the case, get a blank piece of paper and start writing. If you’re more comfortable talking this out, then use your phone video or recorder to do so.