Smoking Cessation Assessment Form

Form Login Account (optional)
New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.
Please take a few minutes to answer the following questions so that we can determine the best methods to help you. You will be contacted by UHCS to schedule an appointment after submitting this form. Feel free to contact us if you have not heard back in a week. Your answers are confidential. UHCS is located in the Forysth building and can be reached at (617) 373-2772 (option 1). Thank you




* Select ONE that best describes you
* How did you learn about RTQ? (select all that apply)
 
* Were RTQ ambassadors helpful?
* Were RTQ ambassadors informative?


* Select all tobacco/nicotine products you use
 
* Do you smoke within 30 minutes of waking up?
* Have you tried to quit in the past?
* How did you try to quit? (select all that apply)
 
* Are you using any other recreational substances e.g alcohol, marijuana, etc.?
* Indicates Response Required