Webform Freedom From Smoking Questionnaire If you have any questions about our tobacco cessation program or this questionnaire, please call 231-392-8487. All information on this questionnaire will be kept confidential. Name Address 1 Address 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home Phone Work Phone Email Which of these best describes your race or ethnic group? (Check all that apply.) African American Asian/Pacific Islander Hispanic Native American/Alaskan Native Other White What is your age? Your History of Tobacco Use At what age did you begin to use tobacco? How many cigarettes do you smoke each day on average? How many times have you tried to quit smoking before? What is the longest period of time you have gone without smoking since you first started? Do you use tobacco in any form other than cigarettes? If yes, please check the box below. Chewing tobacco Cigar E-cigarette Other Pipe Snuff In which settings do you often spend time with others who smoke? (Check all that apply.) At home At work I'm often the only one smoking In social situations Support Network How supportive do you think each of these people will be of your quit attempt? Husband/wife/partner They don't care They don't know They don't want me to quit They're supporting me Children They don't care They don't know They don't want me to quit They're supporting me Friends They don't care They don't know They don't want me to quit They're supporting me Coworkers They don't care They don't know They don't want me to quit They're supporting me Other How did you learn about the American Lung Association's Freedom From Smoking Clinic? Found it on the American Lung Association website From a family member, friend or coworker From my local American Lunch Association office I've used Freedom from Smoking before Online search Other Referred by the Lung HelpLine Saw an ad Form provided by the American Lung Association. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.