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* 1. Contact Information

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* 2. Have you used any form of tobaccco in the past six months?

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* 3. Please check the box beside the statement that best matches your current goals:

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* 4. How old were you when you became a daily smoker?

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* 5. How many years have you used tobacco?

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* 6. What form of tobacco do you currently use?

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* 7. How many cigarettes do you smoke each day?

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* 8. How soon after you wake up do you smoke your first cigarette?

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* 9. When did you last try to quit smoking?

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* 10. Why did you stop last time?

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* 11. How long did you go without smoking that time?

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* 12. Why did you start smoking again?

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* 13. Which method(s) have you tried?

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* 14. Feelings about changing your tobacco use.  Answer the following three questions with respect to the goal you set in Section B:

  Not at all Important Very Important
How important is it for you to change your tobacco use?
How confident are your that you could change your tobacco use?
How ready are you to change?

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* 15. If you continue to use tobacco what POSITIVE benefits do you get from your usage?

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* 16. If you continue to use tobacco what NEGATIVE harm or NEGATIVE effects has your tobacco use caused you?

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* 17. Why do you want to change your tobacco use?

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* 18. What would you gain by changing your tobacco use?

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* 19. What would be hard about changing your tobacco use?

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* 20. What concerns do you have about changing your tobacco use?

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* 21. Do you or other people smoke inside your home?

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* 22. Do you or other people smoke inside your car?

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* 23. Among your friends, family, and co-workers what percentage would you say smoke?

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* 24. How much do you drink of the following caffeinated drinks per day?

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* 25. Have you ever felt you should cut down on your alcohol consumption?

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* 26. Have people annoyed you by criticizing your alcohol consumption?

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* 27. Have you ever felt bad or guilty about your alcohol consumption?

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* 28. Have you ever had a alcoholic beverage first thing in the morning to steady your nerves or get rid of a hangover?

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* 29. Do you use any of the following drugs? (Check all that apply.)

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* 30. Does your drug benefit plan cover quit smoking medications?

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