Description
“I made it to day nine, and then I had one. So that’s it.” The client isn’t asking to start over. They’re asking whether the nine days still count.
For clinicians, coaches and quit advisors
Plenty of worksheets let you print and use them with clients. This one does too. Here is what it adds.
- You may give a client their own blank copy to keep, by email or through a secure patient portal.
- You may use it in groups you run yourself.
- You may print without limit, for as long as you practice.
- And a written license page comes as a separate sheet in the download, so your practice has something to file.
One practitioner. Not transferable to a colleague, and not for resale.
The free page, and what this set adds
Page 1, the countdown grid, is also in the free library on its own. You can use it with clients as it is.
This set, for $2.99, adds the two pages around it: the week before the first box, and the day a box gets missed. Those are the two moments a grid on its own does not cover.
Written for smoking cessation
Not a general habit tracker with the word “smoking” added. The prep page and the slip page are built around the first month of a quit — by a nurse with twenty-five years in pulmonary care who is also a certified quit coach.
Why a full month, and a page for the bad day
Thirty-one days is a whole month on the calendar. A client can start on the first and finish on the last day, with no counting backwards and no half weeks.
Days 29, 30 and 31 are the ones most challenges never ask anyone to keep. They are the reason this one runs to the end of the month.
And a challenge that only records perfect days tends to end on the first imperfect one. The client in the opening line is not in trouble because of one cigarette. They are in trouble because the sheet in front of them has no place to put it. Page 3 is that place. Every box already crossed off stays crossed off.
What you get
Three pages — US Letter and A4 both included — 55 fillable fields.
Plus the license page, in both sizes.
1 — The 31-Day Freedom Challenge
Thirty-one boxes in five named weeks: the physical peak, the habit breaker, the mind reset, the freedom finish, the last stretch. The reason for starting and the person who knows. The reward for the final box. A weekly note on the week that was hardest and what got them through it.
2 — Before Day 1
Filled in before the first box, while nothing is happening yet. The three moments the client already knows will be hard, one answer for each, and what leaves the house before day 1. The start date, a quitline, and who they tell today. The first twenty-four hours planned where it matters: the first hour after waking, the break where they usually stepped outside, the hour after dinner, the last cigarette of the old routine. And what they have ready at home, at work, and with them.
3 — One Day Does Not Undo the Month
Filled in the same day as a slip. What happened, and what came just before. What they needed in that moment. One change for tomorrow, small enough to actually do. Tomorrow’s box number and the boxes already kept. And the one person they tell before they close the page.
How it sits in a session
Page 2 is the opening exercise. The hardest moments come from the client, not from a list, and every answer is decided while calm.
Page 1 goes home and stays visible. The weekly note gives you something concrete to ask about at the next contact.
Page 3 is the one to hand over before it is needed. A client who already has it knows a slip has a next step, and that step is not starting over.
Nothing on these pages is scored.
Three ways to use it
- Hand a client one page, or all three.
- They tick the boxes and type straight into it on a phone or tablet.
- Or print it — the grid was made for crossing off by hand, somewhere they see it every morning.
Two sizes, both fillable
US Letter, 8.5 x 11 in — United States and Canada
A4, 210 x 297 mm — the standard size everywhere else
Both are in the download at no extra cost, and both work the same way: type on screen, or print. The fields do not show on paper.
On the US Letter version, the quitline line names 1-800-QUIT-NOW. On A4 it asks the client to search for the free quitline in their own country.
Before you start
Open the file in Adobe Acrobat Reader — it’s free, on iPhone, Android, Mac and Windows. A browser preview will show the pages, but it won’t reliably keep what a client types or ticks.
Keep the blank original blank. Save filled copies under a new name.
The practice license
One practitioner, unlimited clients, worldwide. Print for your own clients, use one-to-one and in groups you run yourself, send a blank copy to an individual client, and keep a filled copy in a client file where your recordkeeping rules require it. Not for resale, and not transferable to a colleague — each practitioner needs their own. The full terms come as a separate page in the download.
Personalized license copy, on request
The license page carries the name of this set and has fields for your name, your practice, and the date of purchase, so you can complete it yourself and keep it with your records. If you would rather have those details typeset into the page instead of typed into a form field, write to hello@cessationworksheets.com after your purchase and I will send one back. No charge — it is part of the license.
How buying works
Checkout runs through Gumroad, a payment platform used by independent creators worldwide. You pay on their secure checkout page, and your card details never reach me.
The price shown here is $2.99 before tax. VAT or sales tax is added at checkout, based on where you live, so the total can differ from country to country. You see the full amount before you pay.
Charges are processed in US dollars. Outside the United States, your bank converts the amount and may add a small fee of its own.
Straight after payment you get a download link on screen and by email, with both files — A4 and US Letter — and a receipt.
Who wrote this
I am a pulmonary nurse, trained in asthma and COPD. I work in a respiratory outpatient clinic, where I see people with asthma and COPD and run the smoking cessation consultations. I am listed in KABIZ, the Dutch quality register for healthcare professionals, which means I work to the national care standard for tobacco and nicotine dependence.
Evidence-informed and developed with reference to current tobacco-dependence and smoking-cessation guidelines, using CBT-informed behavioral tools to support structured cessation conversations.
Every page is built on national standards for tobacco dependence and on published evidence, and checked against the guidance in each. See the seven guidelines.
No lectures. No scare tactics.
Instant digital download. Nothing is shipped. No refunds once the download has been opened. If the file does not work as described, write to me and I will sort it out.
Support tool only — not medical advice, and not a substitute for the clinical judgment of the practitioner using it.