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Smoking Cessation Program Application Form

1.Your details?(Required.)
2.Your mobile number without the initial zero(Required.)
3.Email(Required.)
4.Age(Required.)
5.Gender :(Required.)
6.Do you live with a partner?(Required.)
7.If yes,does your partner smoke?(Required.)
8.Are you exposed to secondhand smoke ( the smoke of other people's tobacco products')in your workplace or home?(Required.)
9.While you were grown up ,how many of your parents /guardians  smoked at all?(Required.)
10.What type of tobacco do you consume?(Required.)
11.How many years have you been smoking ?(Required.)
12.During the past 12 months , have you tried to stop smoking?(Required.)
13.During any visit of a doctor or other professional in the past 12 months ,were you advice to quit smoking tobacco?(Required.)
14.How soon after you wake up do you smoke your first cigarette?(Required.)
15.How many cigarettes, pipes of tobacco, shisha, sugar flavored shisha do you smoke each day?(Required.)
16.Do you find it difficult to refrain from smoking in places where it is forbidden?(Required.)
17.How did you hear about the program?(Required.)