HII: Freedom from Smoking - Registration and Pre-Survey (2025)

Freedom From Smoking Cessation Program - Registration and Pre-Survey
This registration form and pre-survey will be reviewed by a wellness coach, who will reach out with you to determine a plan to work through Freedom From Smoking together. This is not a group program.
Work Location
Job Type
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Email
example@example.com
How long have you been using tobacco/nicotine?
How many times per day do you use tobacco/nicotine?
What tobacco/nicotine products are you currently using?

Other
How many times have you tried to quit?

On a scale of 1-5, how ready are you to stop using tobacco/nicotine? (1 being "Not ready at all" to 5 being "Very ready to quit right now"

	1	2	3	4	5

1 is Not ready at all, 5 is Very ready to quit right now

On a scale of 1 to 10, how confident are you that you can quit using tobacco/nicotine? (1 being "not confident" to 10 being "extremely confident"

	1	2	3	4	5	6	7	8	9	10

1 is Not Confident, 10 is Extremely Confident

On a scale of 1 to 10, how important is it to you to quit? 1 being "not important" and 10 being "extremely important"

	1	2	3	4	5	6	7	8	9	10

1 is Not Important, 10 is Extremely Important

To what extend to you "agree" or "disagree" with the follwing statements?

Rows	Strongly Disgree	Disagree	Neutral	Agree	Strongly Agree
I am confident I can resist the urge to smoke even if family and friends continue to smoke
I am confident that I can resist the urge to smoke even if I feel tense or stressed
I am confident that I can resist the urge to smoke even if I am having a strong craving
I have a detailed plan of how to arrange my daily routines to manage my triggers

How did you hear about this program? Select all that apply.

Other
BeWell for Life wellness services are available to all HII employees, regardless of medical coverage. Some services may be limited to the HII Family Health Center or online.
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Freedom From Smoking Cessation Program - Registration and Pre-Survey