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  *Zip  *Home Phone  *Work Phone Email Which of these best describes your race or ethnic group? (Check all that apply.) 

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. 

In which settings do you often spend time with others who smoke? (Check all that apply.) 

Support Network

How supportive do you think each of these people will be of your quit attempt? Husband/wife/partner 





How did you learn about the American Lung Association's Freedom From Smoking Clinic? 

Form provided by the American Lung Association.