Maternal smoking questionnaire - about you

The following survey will ask you a number of questions about what might help expectant mothers give up smoking during their pregnancy; all mandatory questions must be answered for you to be entered into the prize draw for a £50 Love to Shop voucher.

Your responses are completely anonymous and will only be used to inform the approach we take to encouraging and helping pregnant women to stop smoking.

The closing date for the questionnaire is Sunday 26 February 2017. Responses received after this date will not be entered into the prize draw.

* 1. What is your date of birth?

* 2. Are you:

* 3. If you have selected that you are a smoker, how many cigarettes do you smoke daily?
(Please select non-smoker if you do not smoke)

* 4. Please select the following option which relates most closely to you, since finding out you're pregnant: 

* 5. If you do not want to give up smoking and/or you have declined help to give up smoking, please explain why below:

* 6. Do you know how harmful smoking during pregnancy can be to your unborn child?

* 7. Out of the following options, please select all of the places that you would trust information from, about yours/your unborn baby's health during pregnancy. 
For each of these options, assume they are from trustworthy organisations like the NHS.

* 8. Please tell us more about where you look for information about yours/your unborn baby's health during pregnancy: (For example have you joined a support group, or online forum etc.)

* 9. Is there anything that would make you give up smoking, if you haven't done so already? This could be extra support, one to one mentoring, financial incentives, further information about the dangers etc. Please put your ideas in the space below:

* 10. What is your postcode?

* 11. And finally, where did you hear about this survey?

Please click next to submit your responses, you will then be given the option to be entered into the prize draw.

Remember, if you would like support in giving up smoking, you can speak to your midwife for help or text 'steps' to 61825.
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