Health Promotion Program

Smoking and Pregnancy Survey

Please take this brief survey of what you know about smoking and pregnancy. This information will help us plan a teaching session for you on this topic. Please do not write your name on this survey.

Please answer the following questions by circling your answer.

1. Do you smoke cigarettes, cigars, or chew tobacco?

Yes No

2. Are you pregnant, or around someone who is pregnant on a daily basis?

Yes No

3. Do you think second-hand smoke is harmful to the child or mother during pregnancy?

Yes No

4. Can you name three effects of smoking in the unborn child?

Yes No

5. Do you know where to find help if you are trying to quit smoking?

Yes No

Thank you for your time!

Kristina and Grace

Purdue University Calumet

Baccalaureate Nursing Students

Hammond, IN