Smoking Cessation Survey
Please take your time and answer these questions as thoroughly and as accurately as possible. This will help make sure that we can meet your goal in the most effective and timely manner.
Full Name
Your answer
Address
Your answer
E-mail Address
Your answer
Age
Your answer
Birthdate
MM
/
DD
/
YYYY
Gender
Marital Status
Your answer
Do you have children? If so, how many?
Your answer
Home Phone
Your answer
Business Phone
Your answer
Are there any other smokers in your household?
What is motivating you to become a non-smoker now?
Your answer
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