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What is your date of birth?

HOW MANY PACKS OF CIGARETTES PER DAY DO YOU SMOKE?

HOW LONG HAVE YOU BEEN SMOKING (ANY AMOUNT) OF CIGARETTES?

WHAT TYPE OF TOBACCO PRODUCTS DO YOU USE? CHECK ALL THAT APPLY

DO YOU SMOKE WITHIN THE FIRST 30 MINUTES OF WAKING UP?

HOW MANY TIMES HAVE YOU TRIED TO QUIT BEFORE?

AT WHAT AGE DID YOU START SMOKING?

HAVE YOU USED PRESCRIPTION MEDICATIONS TO QUIT BEFORE?

IF YES, WOULD YOU LIKE TO USE THE SAME MEDICATION AGAIN?

HOW MOTIVATED ARE YOU TO QUIT?

YOU NEED TO SET A QUIT DATE WITHIN THE NEXT 2-4 WEEKS

YOU WILL NEED TO QUIT SMOKING ON YOUR SET QUIT DATE. WE SUGGEST USING BEHAVIOURAL SUPPORT WITH YOUR MEDICATION

PLEASE CHECK ALL THAT APPLY TO YOU

DO YOU HAVE OTHER MEDICAL HEALTH ISSUES?

DO YOU HAVE ANY ALLERGIES?

ARE YOU CURRENTLY TAKING ANY MEDICATIONS? PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL AND VITAMIN SUPPLEMENTS

ANYTHING ELSE YOU THINK WE SHOULD KNOW?

TREATMENT

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

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