Auriculotherapy Eligibility Test – Laser & Stop

Blank Form (#4)

Laser Auriculotherapy Eligibility Questionnaire

First Name

Last Name

Phone/Mobile

1. How long have you been smoking?

Less than 1 year (10 points)

1 to 5 years (7 points)

More than 5 years (4 points)

2. How many cigarettes do you smoke per day on average?

Less than 5 (10 points)

5 to 10 (8 points)

11 to 20 (5 points)

More than 20 (2 points)

3. Have you tried to quit smoking before?

Yes, multiple times (8 points)

Yes, once (6 points)

No (4 points)

4. If yes, how long did you stay smoke-free?

More than 6 months (10 points)

1 to 6 months (7 points)

Less than a month (4 points)

No attempts (2 points)

5. What motivates you to quit smoking today?

Personal health (10 points)

Family/Loved ones (8 points)

Financial cost (6 points)

Social pressure (4 points)

6. Do you have any personal or family history of heart disease, respiratory diseases (asthma, COPD), or cancer?

No (10 points)

Yes, family history (6 points)

Yes, personal history (3 points)

7. Do you experience persistent symptoms related to smoking (chronic cough, shortness of breath, chest pain)?

No (10 points)

Yes, mild (6 points)

Yes, moderate to severe (3 points)

8. Are you currently taking any medications that might affect your smoking cessation (antidepressants, anxiolytics, etc.)?

No (10 points)

Yes, but compatible with smoking cessation (6 points)

Yes, requires medical advice before quitting smoking (3 points)

9. Has your doctor ever advised you to quit smoking for health reasons?

Yes (10 points)

No (5 points)

Haven’t consulted a doctor recently (3 points)

10. Do you associate smoking with stress or anxiety management?

No, not at all (10 points)

Sometimes (6 points)

Yes, very often (3 points)

11. Are you afraid of gaining weight after quitting smoking?

No, not at all (10 points)

A little (6 points)

Yes, a lot (3 points)

12. Do you feel mentally ready to quit smoking?

Yes, absolutely (10 points)

I'm not sure (5 points)

No, not yet (1 point)

13. Are you familiar with auriculotherapy by LLLT laser as a method to quit smoking?

Yes, and I am convinced of its effectiveness (10 points)

Yes, but I am skeptical (6 points)

No, I don’t know about it (4 points)

14. Are you open to trying alternative or complementary medicine to help you quit smoking?

Yes, completely (10 points)

Yes, but with some doubts (6 points)

No, I prefer traditional methods (3 points)

15. Do you think personal motivation is more important than the method used to quit smoking?

Yes, I believe it’s mainly about willpower (10 points)

I think the method also plays an important role (7 points)

I rely mainly on the effectiveness of the method (4 points)

Score

Evaluation of Results:

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