Proszę zaznaczyć jedną właściwą odpowiedź dla każdego pytania
Lp. Pytanie Odpowiedź Punktacja
1 Jak szybko po przebudzeniu zapala Pan(Pani) pierwszego papierosa?
a. do 5 min 3
b. w 6-30 min 2
c. w 31-60 min 1
d. po 60 min 0
2 Czy ma Pan(Pani) trudności z powstrzymaniem się
od palenia w miejscach, gdzie jest to zakazane? tak 1
nie 0
3 Z którego papierosa jest Panu(Pani) najtrudniej
zrezygnować? z pierwszego rano 1
z każdego następnego 0
4 Ile papierosów wypala Pan(Pani) w ciągu dnia?
a. 10 lub mniej 0
b. 11-20 1
c. 21-30 2
d. 31 i więcej 3
5. Czy częściej pali Pan(Pani) papierosy w ciągu pierwszych godzin po przebudzeniu
niż w pozostałej części dnia?
tak 1
nie 0
6. Czy pali Pan (Pani) papierosy nawet wtedy,
gdy jest Pan (Pani) tak chory/a, że musi leżeć w łóżku? tak 1
nie 0
Suma punktów
Aneks 3
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