Nicotine Dependence Assessment Form
Name:
Age:
Gender:
Female
Male
Other
How many cigarettes do you smoke per day?
How soon after you wake up do you smoke your first cigarette?
Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes
Do you find it difficult to refrain from smoking in places where it is forbidden?
Yes
No
Which cigarette would you hate most to give up?
The first one in the morning
Any other
Do you smoke more frequently during the first hours after waking than during the rest of the day?
Yes
No
Do you smoke even if you are so ill that you are in bed most of the day?
Yes
No
Additional Comments: