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Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.
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At least one selection is required
To enroll in the program, we need to get some information from you. The next several pages will ask you questions about you and your tobacco history. Once you have completed the questions, we will begin this journey together!
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What tobacco product(s) have you used in the past 30 days?
Cigarettes
Chewing tobacco, snuff, or dip
Cigars, cigarillos, or small cigars
Pipe with tobacco
Do you smoke cigarettes every day or some days?
Every day
Some days
How many cigarettes do you smoke per day on the days that you smoke?
How soon after you wake, do you smoke your first cigarette?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Do you use chewing tobacco, snuff or dip every day or some days?
Every day
Some days
How many pouches or tins do you use per week, on the weeks that you use tobacco?
How soon after you wake, do you first use spit tobacco, snuff or chew?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Do you smoke cigars every day or some days?
Every day
Some days
How many cigars, cigarillos or little cigars do you smoke per week on the weeks that you smoke?
How soon after you wake, do you first smoke a cigar, cigarillo, or little cigar?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Do you smoke a pipe with tobacco every day or some days?
Every day
Some days
How many pipes do you smoke per week, on the weeks that you smoke?
How soon after you wake, do you first smoke a pipe?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
Have you used an e-cigarette or other electronic āvapingā product in the past 30 days?
Yes
No
How many days did you use an e-cigarette or electronic āvapingā product in the last 30 days?
Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?
Yes
No
Please send me motivational messages tailored to me and other program events such as appointment reminders, medication shipment, quit anniversaries and more through email and/or text.
Please select text, email, or both below:
Text
Email
Participant feedback helps us improve our services. Providing feedback is voluntary and does not impact your participation in the program. You can choose what you want to share and when you want to share it. After you complete the program, may we contact you about your experience?
Yes
No
Disclaimer :
We do not provide medical care. Talk to your doctor about your plan to quit tobacco and use of nicotine replacement or other quit smoking medicine if you have any questions or problems.
Read Disclaimer?
Yes
Do you have a history of any of the following? Check all that apply.
None
Asthma
Emphysema, Chronic Bronchitis, or COPD
History of seizures
Diabetes
Cancer
Heart disease, irregular heart rate, or angina
Heart attack within the last 12 months
Stroke within the last 12 months
High blood pressure
High blood pressure is controlled with medication
Skin condition (eczema, psoriasis, etc.) or allergies to adhesives
Use dentures or have sensitive gums
Currently pregnant
Yes
No
Due Date?
Currently breastfeeding
Yes
No
Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?
Please select one
No
Yes
Which of these groups would you say best describes you?
White
Black or African American
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaska Native
Hispanic or Latino/Latina
Do you consider yourself to be gay, lesbian and/or bisexual?
Yes
No
Bisexual
Gay or lesbian
Queer
What is the highest level of education you have completed?
Less than grade 9
Grade 9 to 11, no degree
GED
High school degree
Some college or university (includes some technical or trade school)
College or university degree (inlcudes AA, BA, Masters, and PH.D.)
Do you have any mental health conditions, such as anxiety disorder, depression disorder, bipolar disorder, alcohol/drug abuse, or schizophrenia?
Yes
No
Anxiety Disorder
Depression
Bipolar Disorder
Schizophrenia and Schizoaffective Disorders
Attention-Deficit/Hyperactivity Disorder (ADHD)
Posttraumatic Stress Disorder (PTSD)
Other
Substance use condition?
Yes
No
During the past two weeks, have you experienced any emotional challenges such as excessive stress, feeling depressed or anxious?
Yes
No
During the past two weeks, have you experienced any emotional challenges that have interfered with your work, family life, or social activities?
Yes
No
Do you believe that these mental health conditions or emotional challenges will interfere with your ability to quit?
Yes
No
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