Smoking Cessation Monitoring Form
Please fill out this form to monitor your progress in quitting smoking.
Full Name
First Name
Last Name
Date of Quit Attempt
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of Cigarettes Smoked Today
Rate your craving level from 0 (none) to 10 (extreme)
1
1
2
3
4
Best
5
1 is , 5 is Best
Select any triggers you experienced today
Stress
Social Situations
Alcohol
Boredom
Other
Comments or Notes
Submit
Should be Empty: