Smoking is the scourge of coronary heart disease
Questionnaire on smoking in patients with cardiovascular disease
●Name: ___________ ●Gender: Male__ Female__ ●Year of birth: ____
What kind of disease do you have: Hypertension□ Coronary heart disease□ Wu Yan, Department of Cardiovascular Medicine, Peking University People’s Hospital
Hyperlipidemia□ Diabetes□
Other or don’t know□
Do you know that smoking can cause cardiovascular disease? Yes□ Don’t know□ Do you know that smoking can cause cardiovascular disease?
Do you smoke? Never smoked (end of survey)□
Used to smoke, now quit ____ years (end of survey)
Still smoke ____ and have smoked for a total of ____ years. Please continue answering the following questions.
● Do you want to quit smoking? Don’t want to quit□ Haven’t thought about it yet□ Want to quit immediately□
How many cigarettes do you smoke on average per day? ____
How soon after you wake up do you smoke your first cigarette?
Within 5 minutes□ Within half an hour□ Within 1 hour□ After 1 hour
Do you find it unbearable to smoke in public areas (shopping malls, buses, etc.) where smoking is not allowed?
I find it difficult□ I can tolerate it□
Which cigarette do you think you are most reluctant to give up? First cigarette in the morning□ Other times□
When do you smoke the most every day? A few hours after getting up□ Other times□
Would you still smoke if you were bedridden due to illness? Yes□ No□ No
Would you like to participate in a smoking cessation program jointly organized by the Chinese Medical Association and the government: Yes□ No
If you would like to participate in the program, please leave your phone number at ____________