Loading questionnaire please wait...
Smokefree Questionnaire
Please complete the form below. Please use the text boxes provided to add any comments.


Smokefree Questionnaire
Ward you stayed in
Today's date

Smokefree Questions for People who use our services who have had Hospital stays since October 2017
1What is your current Smoking/Vaping status?
Non-smokerEx-smokerTobacco SmokerVapingTobacco Smoker & Vaping
2Were you aware prior to your admission that the Hospital and grounds are smokefree?
YesNo
3Do you support the Hospital being smokefree?

Please state why?
YesNo
4Has or did the hospital being smokefree help you to reduce your smoking or completely quit smoking during your stay?
YesNoN/A
5If you are a tobacco smoker, did you receive, or are you receiving support to help you stop/reduce smoking during your Hospital stay?

If yes, please state what aspects of the support you found most helpful?
YesNoN/A
6If you are a smoker, which of these Nicotine Replacement products did you use or would you prefer to use instead of smoking during a Hospital stay?
(NRT) Nicotine Replacement Products – Patch, Lozenge or GumDisposable daily E-cigaretteYour own Vape/E-cigaretteN/A
7During your time in Hospital, have you or were you affected by Vapour from use of E-cigarettes/Vapes?

If Yes please state how you were affected
YesNo
8Do you think there should be designated areas for Vaping?
YesNo
9If Yes, please state where you think these designated areas should be?
In the wardIn the gardensBoth