Smoking and Tobacco Use
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1. Default Section
1
. How are you affiliated with New York Methodist Hospital
How are you affiliated with New York Methodist Hospital
Employee
Resident/Medical Student
Volunteer
Other
2
. What is your gender?
What is your gender?
Male
Female
3
. What is your age group?
What is your age group?
16-24
25-45
46-60
61 or older
4
. Do you use tobacco products?
Do you use tobacco products?
Never
Occasionally (socially)
Daily
Other (please specify)
5
. What type of tobacco product(s) do you use?
What type of tobacco product(s) do you use?
Cigarettes
Cigars/pipe
Chew/dip
Other
not applicable
6
. At what age did you start smoking?
At what age did you start smoking?
10-18
19-25
26-40
41 or older
not applicable
7
. Have you ever tried quitting?
Have you ever tried quitting?
Yes
No
Think about it
not applicable
8
. Do you feel that smoking affects your health?
Do you feel that smoking affects your health?
Yes
No
Not sure
9
. What type of program do you think would be helpful to you if you considered quitting?
What type of program do you think would be helpful to you if you considered quitting?
General information session
Private counseling session
Phone call from a health care professional
Step by step program with weekly meetings
Support group
not applicable
Other (please specify)
10
. Would you like to receive more information regarding smoking/tobacco cessation for yourself or a friend/family member?
Would you like to receive more information regarding smoking/tobacco cessation for yourself or a friend/family member?
No
Yes (please leave contact info)
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