ASQ Intake Questionnaire (Chinese)

National Quitline Data Warehouse

0856 NQDW Att C2_NQDW_ASQ_Intake Questionnaire_CHINESE

OMB: 0920-0856

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California Smoker’s Helpline

NRT Screening (Enhanced Services)


Form Approved

OMB No. 0920-0856

Exp. Date xx/xx/XXXX







National Quitline Data Warehouse

Intake Questionnaire

(Asian Smoker’s Quitline: Chinese)











Public reporting burden of this collection of information is estimated to range from 1-10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0856)









Asian Smokers’ Quitline (ASQ) Chinese Intake


This is a free service to help people quit smoking. We offer help through the mail and also over the phone. To provide the best possible service, calls may be monitored and recorded, but will be kept private. I need to ask you a few questions to see what we can do for you, and all of your responses are voluntary. Is that OK?


這裡是提供免費協助戒煙的服務中心,由加州大學醫學院管理。我們的服務都是通過郵寄和電話提供的。為了提供最佳服務, 談話可能被聽和錄音。我想先問您一些問題,您的回答純屬自願,也就是說您有權不回答任何問題。您所有的回答都是保密的,可以嗎? Yes  No

1) Are you calling for yourself or someone else? 您打電話來, 是您自己要戒煙, 還是為別人索取資料?

 Yourself  Someone else



2) What’s your year of birth? 請問您的出生年月日?

_______  Refused


IF REFUSED: Then how old are you?

那您今年幾歲? _________  Refused Unwilling, but >= 18 yrs. old


3) How did you hear about us? 您是怎麼知道我們這個中心及所提供的服務?


Ads:  TV  Radio  Newspaper/ Magazine

 Billboard/ Bus Sign

 Phone Book  Web

Referrals:  VA  Hospital  Clinic/ Doctor’s Office

 Dentist/ Dental Hygienist

 Friend/ Family

 WIC

 Pharmacy  School  Non-profit Org.

 Insurance/HMO/MediCal  Other

 Don’t know

 Refused

Promotional Materials

 Card (Gold, Salud, Quit Now)

 Patch Voucher

Brochure/Pamphlet

 Postcard


If any Referral source (e.g. VA through Insurance/HMO/MediCal above):

Did you receive anything, such as a card or brochure with our number on it?

您曾收到一張有我們電話號碼的卡片或小冊子嗎?

 No  Yes…Postcard  Yes…Re-engagement letter

 Yes… Card  Yes…Magnet  Don’t Know

 Yes…Patch Voucher  Yes…Brochure/ Pamphlet  Refused

If PROMOTIONAL MATERIALS:

Where did you get it?

您是從哪裏拿到金卡/小冊子/章程的呢?

 VA  Hospital  Clinic/ Doctor’s Office

 Dentist/ Dental Hygienist  Friend/ Family  WIC

 Pharmacy  School  Non-profit Org.

 Insurance/HMO/MediCal  CSH  Other


4) Do you smoke cigarettes every day, some days, or not at all (already quit)?

您每天都抽煙,有些日子抽煙,還是完全不抽呢?

 Every day

 Some Days…

 Not at all (already quit)…

 Other form of tobacco…


a. If EVERY DAY: On average, how many cigarettes do you smoke per day?_

平均來講,您每天抽幾支煙 ? ____  Don’t know  Refused

Do you usually smoke menthol or non-menthol cigarettes?

您通常抽薄荷味道還是沒有薄荷味道的香煙?

 Menthol  Non-menthol  No usual type  Don’t know  Refused  Not asked


b. If SOME DAYS: How many days per week do you smoke? ­­­

您每週有幾天吸? ______  Refused

On average how many cigarettes do you smoke per day on the days you smoke?

平均來講,在你抽煙的日子您每天抽幾支煙 ?______  Refused


Do you usually smoke menthol or non-menthol cigarettes?

您通常抽薄荷味道還是沒有薄荷味道的香煙?

 Menthol  Non-menthol  No usual type  Don’t know  Refused  Not asked


c. If NOT AT ALL: When did you quit? 什麼時候戒的煙? _______/_______/_______  Don’t know  Refused

How many days per week did you smoke? ­­­戒煙以前,您每一個星期有幾天抽煙?______

 Don’t know  Refused

On average how many cigarettes did you smoke per day on the days you smoked? 在您煙的日子,平均來講每天會抽幾枝煙?______

 Don’t know  Refused

Did you usually smoke menthol or non-menthol cigarettes?

您通常抽薄荷味道還是沒有薄荷味道的香煙?

 Menthol  Non-menthol  No usual type  Don’t know  Refused  Not asked


5) How soon after you wake up do/did you usually smoke your first cigarette?

每天早上醒來後,您大約多久以後抽第一支煙?

 0-5 mins  6-30 mins  31-60 mins  +60 mins  Don’t know  Refused


6a) Do you currently use any other form of tobacco, such as chew/snuff, cigars, or pipes? 現在您有沒有使用其他煙草? (例如咀嚼煙,鼻煙,雪茄或煙斗)?

 Yes …  No …

 Don’t know …  Refused…

6b) Do you currently use any other form of tobacco, such as chew/snuff, cigars, or pipes?

現在您有沒有使用其他煙草? (例如咀嚼煙,鼻煙,雪茄或煙斗)?

Yes …  No …  Don’t know  Refused…


6c) Which ones?哪幾種?

 Chew/snuff  Cigarillos (小雪茄)  Cigars  Pipes  Hookah (水煙筒)  Other: ________

If CHEW/SNUFF: M How much tobacco do you use per week?

每個星期用多少? _____

Is that cans or pouches? 是罐還是袋? Don’t know  Refused


If NO to current use (7b): When did you quit? 甚麼時候戒的呢?_____/_____/______

 Refused


If CIGARS: M How many do you smoke per week? 每個星期抽幾枝?______________

 Don’t know  Refused


7) Have you ever used an e-cigarette? 你使用過電子煙嗎?


 Yes

 No

 Don’t know

 Refused

 Not asked

  1. Do you currently use e-cigarettes every day, some days, or not at all?

你現在是每天用電子煙,有些日子用,還是不再用了?

Every day…

Some days….

Not at all…

Don’t know

Refused

Not asked


  1. When was the last time you used an e-cigarette?

你最後一次使用電子煙是在甚麼時候?

____/____/________.

Don’t know…

Refused….

Not asked …



  1. In the last 30 days, how many days did you use an e-cigarette?

______ days (0-30)

過去的30天你有幾天使用電子煙?

Don’t know

Refused

Not asked


  1. Do you think you will quit using e-cigarettes within 1 year?

你會在一年之内把電子煙戒斷嗎?

Yes…

No…

Don’t know…

Refused…
Not asked…


  1. Do you think you will quit within a month, within 6 months, or after 6 months?

你會在一個月内,六個月内還是六個月後戒呢?

Within a month

Within 6 months

After 6 months

Don’t know

Refused

Not asked


8) One of two options depending if AQ or not:

a) IF ALREADY QUIT: Are you currently using the nicotine gum, patch, or Zyban or Chantix? 現在您有使用尼古丁口香糖,貼片、 Zyban 或是Chantix 嗎?

Yes  No  Don’t know  Refused


b) If YES: Which ones? 哪幾種?

 Patch  Gum  Zyban  Chantix  Other: ________

c) IF NOT ALREADY QUIT: Do you plan to quit smoking within a month?

您打算在一個月之内戒煙嗎?

 Yes  No  Don’t know  Refused


9) Do you plan to use any quitting aids such as the nicotine gum, patch, or Zyban or Chantix to help you quit this time? 這次戒煙,你有打算用任何助藥物,例如尼古丁貼片,口香糖,ZybanChantix來幫助你嗎?

 Yes  No  Don’t Know  Refused


If YES: Which ones? 哪幾種? Patch  Gum  Zyban  Chantix

 Other: ___


10) Do you have any form of health insurance, such as Kaiser or MediCal?

你有醫療保險嗎?例如:Kaiser或政府保險計劃

 Yes  No  Don’t know  Refused


IF YES: What is the plan name? 是哪一個保健計劃? ______


Now I have a few health questions that are related to smoking.

現在我想問您幾個可能因吸煙引起的健康問題


11) Have you ever been told by a doctor that you have HIGH BLOOD PRESSURE?

醫生說過有高血壓

 Yes  No  Don’t know  Refused


IF YES: Is it under control? 有沒有用藥物來控制呢?

 Yes, with medication

 Yes, w/o medication

 No, not controlled

 Don’t know

 Refused


12) Have you ever been told by a doctor that you have DIABETES醫生說過您有糖尿病嗎?

 Yes  No  Don’t know  Refused


If YES: Do you use insulin or take pills for it? 是用胰島素還是用藥丸控制的呢

 Yes, pills

 Yes, insulin

 Yes, both pills and insulin

 No, neither pills nor insulin

 Don’t know

 Refused


13) Have you ever had a heart attack? 您曾有過心臟病發作嗎?

 Yes  No  Don’t know  Refused

If YES: Was it within the last 6 months? 發生在過去六個月之内嗎?

 Yes  No  Don’t know  Refused


14) Have you ever had a stroke? 有過中風嗎?

 Yes  No  Don’t know  Refused

If YES: Was it within the last 6 months? 發生在過去六個月之内嗎?

 Yes  No  Don’t know  Refused


15) We send free materials to everyone, so may I have your zip code? 我們會把免費的戒煙資料寄給您,請問您的郵政編碼是幾號?____________


16) I have a few demographic questions. First, I need to verify…Are you male or female?

我們還有幾個簡單的問題想問問您首先,

我們需要確實一下您的性別, 您是男/女性, 對嗎?

 Male  Female  Refused  Not asked

If FEMALE and </= 45 yrs. old: We also have special information for pregnant clients, is there any chance you may be pregnant? 我們也有一些給孕婦的特別資料,請問你現在有懷孕嗎?

 No  Yes  Don’t know  Refused  Not asked

If YES: When is your baby due? 預產期是在甚麼時候?

____/____/____ DK  R  Not asked


17) What is your ethnic background?

您屬於哪個族裔?

 White  Black/African American  Hispanic/Latino

 Asian/ Pacific Islander

What is your specific Asian background? (drop down menu)

裔中哪一個族裔

 American Indian or Alaska Native

Do you have a particular tribal affiliation?

您有特殊的部落宗族背景嗎

 Yes  No  Refused  Not Asked

If yes, link to tribe menu

 More than one of the above

Check ANY/ALL that apply:

 White

 Asian/Pacific Islander

What is your specific Asian background? (drop down menu)

裔中哪一個族裔

 Black/African American  Hispanic/Latino

 American Indian/Alaska Native (tribe menu)

Do you have a particular tribal affiliation?

您有特殊的部落宗族背景嗎

 Yes  No  Refused  Not Asked

If yes, link to tribe menu

 Other ____________________


18a) In which country were you born?你是在哪一個國家出生呢?

 U.S.  Other

 Korea  Don’t know

 Vietnam  Refused

 China  Not asked


18b) What year did you come to U.S?你是在哪一年來美國的?____ Don’t know Refused


19) What is the highest level of education that you have completed?

請問您的教育程度是甚麼?

 Never attended school  2-yr College degree (AA)

 Grades 1-8  4-yr, College or Univ degree (BA, BS)

 Grades 9-12 (No Diploma)  Post-Graduate degree (Masters, Ph.D)

 GED  Refused

 High School Diploma  Don’t know

 Some College or Trade School, No Degree  Not asked


20) What is the age of the youngest person in your household? ­­________  D  R  Z

現在跟您一起住的家人中, 年紀最小的今年幾歲?


21) Have you been told you have arrhythmia (an irregular heart beat/rhythm that requires medication)? 你曾經有心律不齊需要服藥嗎?

 Yes  No

 Don’t know  Refused


22) Have you been told you have angina (serious heart pain/chest pain with exertion)? 你曾經有心絞痛嗎?(嚴重的心疼痛/胸口痛及發緊)

 Yes  No

 Don’t know  Refused


23) Have you ever had an allergic reaction to adhesive tape? 貼膠布後曾經有過敏的反應嗎?

 Yes, severe (problems breathing or hospitalization)

 Yes, mild (rash)

 No

 Don’t know

 Refused


24a) What dosage are you on?你用的是什麽劑量呢?

If patch: 21 mg (Step 1)

14 mg (Step 2)

7 mg (Step 3)

 Don’t know

 Refused


24b) What dosage are you on? 你用的是什麽劑量呢?

If gum: 4 mg

2 mg

 Don’t know

 Refused


If has medical contraindications (any box needing MD OK checked) :

25) We need to get a Doctor’s OK for you to use patches. Is that OK? 我們需要先得到您的醫生的允許才可以讓您使用貼片,您覺得可以嗎?

 Yes (Ok to contact MD)

 Doesn’t have an MD (Ok from an MD will be required)

 No (Not ok to contact MD —client will be ineligible)… go to ineligible ending


If Yes…

What is his/her name? (or clinic/hospital name?) /她叫甚麼名字?(或診所/醫院的名字?)

Name______________________ _______________ Don’t know  Refused

And the phone Number? 電話號碼呢?

_______________________  Don’t know  Refused

Do you happen to know the fax number? 您有他/她的傳真號碼嗎?_____________________  Don’t know  Refused


26a) If Ok to get MD consent, but no MD or Don’t Know

If you call us back with your MD phone or fax number, you may be able to receive patches sent directly to you. Or, in most cases, Medi-Cal will pay for the patches or other quitting aids if you have two things:

在取得你的醫生的電話或者傳真號碼後打電來你就有可能直接收到貼片或你有這兩張文件


  1. A prescription from your doctor 醫生的處方及戒煙專綫的證書一併拿到藥房

  2. A certificate from us

Take these to your pharmacy.

大多數的情況白卡都會支付尼古丁貼片或其他戒煙輔助藥的費用


26b) If Not okay to get MD consent:

Ok, we still want to offer you our free phone counseling. The session is about a half hour and helps you prepare to quit/stay quit. Would you like to speak to a smoking cessation counselor?

好吧,這樣我們還是可以提供給您大概30分鐘免費的電話諮詢,戒煙顧問會幫助您了解怎樣準備戒煙/保持不。您願意跟我們的顧問談話嗎?

 Yes (counseling)  No (materials)


27) We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year?

在一年內,我們希望能和一小部分曾經打電話來的人士通電話,以便了解我們服務的成效。到時候,我們可以打電話給您嗎?

 Yes  No  Refused  Not asked


You’ll be receiving your materials in the mail in about a week and we’ll let you know when we hear from your doctor.

一個星期左右,您將會收到我們寄給您的戒煙資料,當我們接到您醫生的囘覆時我們會再通知您。


The next step is to talk with a smoking cessation counselor for about 30 minutes and they’ll help you prepare to quit/stay quit. Do you have time to do the counseling now if a counselor is available?

下一步是跟戒煙顧問交談, 戒煙顧問會幫助您準備戒煙/保持不再抽煙。假如我們的戒煙顧問現在有空,您有沒有大概30 分鐘的時間談話呢?

Yes Let me see if one is available讓我先看看有沒有顧問有空 . . . Available

No… Not available

Refused Counseling …


If no medical contraindications:

28) We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? (skip this consent question for cx’s that refuse ph# or no phone # is given) 在一年內,我們希望能和一小部分曾經打電話來的人士通電話,以便了解我們服務的成效。到時候,我們可以打電話給您嗎?

 Yes  No  Refused  Not asked


You’ll be receiving your materials and patches in the mail in about a week, and by the way, they will come separately. 大約一個星期左右您將會收到兩個分別裝有戒煙資料及尼古丁包裹


The next step is to speak with a smoking cessation counselor for about 30 minutes and they’ll help you prepare to quit/stay quit. Do you have time to do the counseling now if a counselor is available?

下一步是跟戒煙顧問交談,戒煙顧問會幫助您準備戒煙/保持不再抽煙。

假如戒煙顧問現在有空,您有沒有大概30 分鐘的時間談話呢?


Yes Let me see if one is available讓我先看看有沒有顧問有空. Available

No… Not available

Refused Counseling …


If not eligible for NRT (e.g., no phone, address, no voucher #, etc):

  1. a.We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內,我們希望能和一小部分曾經打電話來的人士通電話,以便了解我們服務的成效。到時候,我們可以打電話給您嗎?

 Yes  No  Refused  Not asked

  1. b.You’ll be receiving your materials in the mail in about a week. Do you have time to do the counseling now if a counselor is available? 大約一星期左右,您就會收到戒煙資料。您現在有時間跟戒煙顧問談談有關戒煙的問題嗎?

 Yes  No  Not asked


29) No (materials only)

  1. We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內,我們希望能和一小部分曾經打電話來的人士通電話,以便了解我們服務的成效。到時候,我們可以打電話給您嗎?

 Yes  No  Refused  Not asked


  1. You’ll be receiving your materials in the mail in about a week. If you would like to receive counseling in the future, you can always call us back. (結束語...) 大約一星期左右,您就會收到戒煙資料。如果您將來覺得需要戒煙顧問談談,請隨時打電話給我們。


30) We offer help over the phone. The session is about a half hour and helps you prepare to quit/stay quit. Would you like to speak to a smoking cessation counselor? 我們提供約30 分鐘的電話戒煙輔導,戒煙顧問可以幫助您預備如何戒煙/保持不再抽煙。您願意跟他談談嗎?

 Yes (counseling)  No (materials)


Yes (counseling)

  1. a.We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內,我們希望能和一小部分曾經打電話來的人士通電話,以便了解我們服務的成效。到時候,我們可以打電話給您嗎?

 Yes  No  Refused  Not asked


  1. b.You’ll be receiving your materials in the mail in about a week. Do you have time to do the counseling now if a counselor is available? (結束語...) 大約一星期左右,您就會收到戒煙資料。您現在有時間跟戒煙顧問談談有關戒煙的問題嗎?

  2.  Yes  No  Not asked


No (materials only)

  1. We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內,我們希望能和一小部分曾經打電話來的人士通電話,以便了解我們服務的成效。到時候,我們可以打電話給您嗎?

 Yes  No  Refused  Not asked


  1. You’ll be receiving your materials in the mail in about a week. If you would like to receive counseling in the future, you can always call us back.

(結束語...) 大約一星期左右,您就會收到戒煙資料。如果您將來覺得需要戒煙顧問談談,請隨時打電話給我.

Updated 07/13/2012 Page 20 of 20


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