Smoking Cessation Questionnaire

Please complete the following form, then click Submit.

  1. (required)
  2. (required)
  3. (required)
  4. Is your work stressful?
  5. Do others in your family smoke?
  6. Why did you start? (check all that apply)
  7. What do you "get" from smoking? (check all that apply)
  8. When do you smoke? (check all that apply)
  9. Do you have any health problems? (check all that apply)
 

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