Age of student:    _________

Grade level:          _________

Male/Female:        _________

1.  Do you smoke?  ____Yes____No

        If yes, how many cigarettes do you smoke a day?
        _____Less than a half a pack (10)
        _____Less than one pack (20)
        _____More than one pack

2.  Do have friends that smoke?  ____Yes____No

3.  Do one or more of your parents or legal guardians smoke?  ____Yes____No

4.  Where do you obtain your money for your habit?
        _____Part-time job
        _____Parents
        _____Get cigarettes from my friends
        _____Other Please specify)___________________________________

5.  Do you think you could quit at any time?  ____Yes____No

6.  If you are a smoker, at what age did you start?  ______

7.  Are you aware of specific health risks associated with smoking?  ____Yes____No