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Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

Tell Us More About Yourself

All fields required All questions are required At least one selection is required

To enroll in the program, we need to get some information from you. The next several pages will ask you questions about you and your tobacco history. Once you have completed the questions, we will begin this journey together!

When you enroll in My Life My Quit, you will have access to free and confidential text, phone and online support. Please complete the form to get started.

* Required

What is your preferred language?English
Spanish
Other

Please enter your first name.

Please enter your last name.

What is your preferred phone number?

Please enter your Phone Extension if you have one:

Please enter your zip code.

Please tell us when you were born.

In which program would you like to participate?Why?Online Only
Phone + Online

Please enter your email address.

Password
(include uppercase & lowercase characters, digits, non-alphabetic characters (e.g. !, $, #, %))

Confirm Password

I have read and accept the Terms / Privacy Policy

What types of tobacco have you used in the past 30 days?

Cigarettes

Do you smoke cigarettes every day or some days?Every day
Some days

How many cigarettes do you smoke per day on the days that you smoke?

How soon after you wake, do you smoke your first cigarette?Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Chewing tobacco, snuff, or dip

Do you use chewing tobacco, snuff or dip every day or some days?Every day
Some days

How many pouches or tins do you use per week, on the weeks that you use tobacco?

How soon after you wake, do you first use spit tobacco, snuff or chew?Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Cigars, cigarillos, or small cigars

Do you smoke cigars every day or some days?Every day
Some days

How many cigars, cigarillos or little cigars do you smoke per week on the weeks that you smoke?

How soon after you wake, do you first smoke a cigar, cigarillo, or little cigar?Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Pipe with tobacco

Do you smoke a pipe with tobacco every day or some days?Every day
Some days

How many pipes do you smoke per week, on the weeks that you smoke?

How soon after you wake, do you first smoke a pipe?Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?Why?Yes
No

How many days did you use an e-cigarette or electronic “vaping” product in the last 30 days?

People use e-cigarette/e-vaping products for a variety of reasons, are you currently using e-cigarettes/e-vaping products to quit smoking?Why?Yes
No

Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?Yes
No

By checking the box you agree to receive motivational, informational, coaching and other types of messages from the Quitline to support you. Message frequency will vary. Reply HELP for help. Reply STOP to stop (or cancel). Message and data rates may apply.

Please select text, email, or both below:

Text

Participant feedback helps us improve our services. Providing feedback is voluntary and does not impact your participation in the program. You can choose what you want to share and when you want to share it. After you complete the program, may we contact you about your experience?Yes
No

Disclaimer : We do not provide medical care. Talk to your doctor about your plan to quit tobacco and use of nicotine replacement or other quit smoking medicine if you have any questions or problems.
Read Disclaimer? Yes

Do you have a history of any of the following? Check all that apply.

None

Asthma

Emphysema, Chronic Bronchitis, or COPD

History of seizures

Diabetes

Cancer

Heart disease, irregular heart rate, or angina

Heart attack within the last 12 months

Stroke within the last 12 months

High blood pressure

High blood pressure is controlled with medication

Skin condition (eczema, psoriasis, etc.) or allergies to adhesives

Use dentures or have sensitive gums

Currently pregnant Yes No

Due Date?

Currently breastfeeding Yes No

Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?

Which of these groups would you say best describes you?

White

Black or African American

Asian

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Hispanic or Latino/Latina

Do you consider yourself to be gay, lesbian and/or bisexual?Why?Yes
No

Bisexual

Gay or lesbian

Queer

What is the highest level of education you have completed?Less than grade 9
Grade 9 to 11, no degree
GED
High school degree
Some college or university (includes some technical or trade school)
College or university degree (inlcudes AA, BA, Masters, and PH.D.)

Do you have any mental health conditions, such as an anxiety disorder, depression disorder, bipolar disorder, schizophrenia, Attention-Deficit/Hyperactivity Disorder (ADHD), Posttraumatic Stress Disorder (PTSD) or substance use disorder?Why?Yes
No

Anxiety Disorder

Depression

Bipolar Disorder

Schizophrenia and Schizoaffective Disorders

Attention-Deficit/Hyperactivity Disorder (ADHD)

Posttraumatic Stress Disorder (PTSD)

Substance use disorder

Other

During the past two weeks, have you experienced any emotional challenges such as excessive stress, feeling depressed or anxious?Why?Yes
No

During the past two weeks, have you experienced any emotional challenges that have interfered with your work, family life, or social activities?Why?Yes
No

Do you believe that these mental health conditions or emotional challenges will interfere with your ability to quit?Yes
No

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Tell Us About Yourself

Medical Conditions

Tell Us More About Yourself

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