Tobacco Use Intake Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
Back
Submit
Next
How long have you been using tobacco products?
less than 6 months
6 -12 months
1-3 years
5 years +
Have you tried to quit using tobacco products before?
If "yes" to question above, what have you tried to stop using tobacco products?
Are there any health conditions that run in your family?
Signature
Should be Empty: