Vaping Cessation Intake Questionnaire
Full Name
Age
Contact Information
How long have you been vaping?
How often do you vape?
Nicotine strength (mg/mL)
What triggers your vaping?
Have you tried to quit before?
Yes
No
If yes, what methods have you used?
What challenges do you face in quitting?
What is your main reason for quitting?
Do you have support from family/friends?
Yes
No
Any health conditions or concerns?
Anything else you'd like to share?