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MetroHealth Nicotine Dependence Prevention and Treatment Program
Any information given on this form is voluntary and will remain confidential. It will help us to determine your individual needs to quit so that the correct treatment is available for you.
Please ask the program leader if you have any questions about this form at
216-778-3031
or email
mhquitsmoking@metrohealth.org.
What program(s) would you like to enroll in?
*
Nicotine Dependency Screening in English (Video) - 1-on-1 help
Nicotine Dependency Screening in English (Telephone) - 1-on-1 help
Nicotine Dependency Screening in Spanish (Video) - 1-on-1 help
Nicotine Dependency Screening in Spanish (Telephone) - 1-on-1 help
Freedom from Smoking Class in English (On-Site) - Group/class help
Freedom from Smoking Class in English (Video) - Group/class help
Freedom from Smoking Class in Spanish (Video) - Group/class help
First Name
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Last Name
*
List other names you have gone by:
Email Address
*
Street Address
*
Birthdate:
*
+
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
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Phone Number
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Best time to contact you
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Morning
Afternoon
Evening
Are you a MetroHealth patient?
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Yes
No
Which of these describes your ethnic group?
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White
African American
Hispanic
Asian/Pacific Islander
Native American/Alaskan Native
Other
Other
What is your gender identity?
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Man
Woman
Non-binary
Prefer not to say
How is your health?
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Good
Fair
Poor
Very Poor
What type(s) of nicotine products do you use? Check all that apply.
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Bidis and Clove Cigarettes
Chewing Tobacco
Cigar
Cigarettes
Dissolvable Tobacco
E-cigarettes
Hookahs
Kreteks
Pipe
Snuff
N/A
Do you have any questions or concerns at this time?
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