* 1. Address

* 2. How did you hear about the Live Tobacco Free Program?

* 3. Why did you chose to participate in this program? (check all that apply)

* 4. What is your gender?

* 5. What is your date of birth?

Date
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* 6. How would you describe yourself? (check all that apply)

* 7. What is your insurance coverage? (check all that apply)

* 8. Have received any of the following adult immunizations within the past 12 months? (check all that apply)

* 9. Which of the following best describes your current income?

* 10. Which form of nicotine do you currently use? (Check all that apply)

* 11. About how much do you currently use per day?

* 12. Would you say in general your health is:

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