SELF-DETERMINATION TEST

1. How important for you to stop smoking?

3	Very important
2	Moderate importance
1	Less importance

2. How determine are you to stop smoking at this moment?

3	Very determined
2	Moderate determinated
1	Less determinated

 

 

 

3. What is the reason for you to stop smoking?

4	Existing health problem?
3	Concern about future health problem?
2	High cost of cigarettes?
1	Good health for the family?

 

 

 

4. What confidence level you have in this treatment?

3	Very confident
2	Moderate confidence
1	Less confident

 

Tabulation table
Total Points	Outcome
4-6	Less Determined
7-10	Medium Determined
11-13	Highly Determined
The Higher the value, the higher determination to stop smoking!