Stop Smoking Support Form
Enter your full name:
Enter your e-mail address:
Smoker's History Info
Why do you want to quit smoking (list as many reasons as you can)?
Have you ever tried to quit before?
Yes
No
How many times have you tried to quit?
0 times
1 time
2 to 3 times
4 times or more
What method(s) did you use in your previous attempt(s) to quit smoking (cold turkey, the patch, drugs, hypnosis, etc.)?
How many packs of cigarettes a day do you smoke?
1 pack or less
up to 2 packs
2 packs to 5 packs
5+ packs or more
How long have you been smoking?
1 year or less
1 year to 3 years
3 years to 5 years
5 years to 10 years
10 years to 30 years
30+ years or more
Stop Smoking Form
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