Smoking Cessation Program Application Form Question Title * 1. Your details? Name Company OK Question Title * 2. Your mobile number without the initial zero OK Question Title * 3. Email OK Question Title * 4. Age 18-24 25-34 35-44 45-54 55-64 65+ OK Question Title * 5. Gender : Male Female OK Question Title * 6. Do you live with a partner? Yes No OK Question Title * 7. If yes,does your partner smoke? Yes No OK Question Title * 8. Are you exposed to secondhand smoke ( the smoke of other people's tobacco products')in your workplace or home? Yes No OK Question Title * 9. While you were grown up ,how many of your parents /guardians smoked at all? None One More than one Don't know OK Question Title * 10. What type of tobacco do you consume? Cigarettes Tobacco pipe Shisha Sugar flavored Shisha OK Question Title * 11. How many years have you been smoking ? 1-2 years 3-4 years 5+ years OK Question Title * 12. During the past 12 months , have you tried to stop smoking? Yes No Don't know OK Question Title * 13. During any visit of a doctor or other professional in the past 12 months ,were you advice to quit smoking tobacco? Yes No No visit during the past 12 months Don't know OK Question Title * 14. How soon after you wake up do you smoke your first cigarette? Within the first 60 min After 60 minutes OK Question Title * 15. How many cigarettes, pipes of tobacco, shisha, sugar flavored shisha do you smoke each day? OK Question Title * 16. Do you find it difficult to refrain from smoking in places where it is forbidden? Yes No OK Question Title * 17. How did you hear about the program? OK DONE
