Quit Smoking Cigarettes
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Quit Smoking Cigarettes
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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Demographics
Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
Gender
Male
Female
Other
Ethnicity
Height
Weight
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
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example@example.com
Preferred language if other than English
Please Select
Spanish
Russian
Ukrainian
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Medications
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Past Medical History
What have you been diagnosed with? When?
What allergies do you have, and what symptoms do you experience?
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Smoking History
Have you tried to quit smoking before? If so, describe your experience (methods, length of abstinence, etc.)
How long have you been smoking?
How many cigarettes do you smoke per day?
How much time goes by between you waking up in the morning to having your first cigarette?
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Social History
Describe your diet
Describe your alcohol use
Do you use other tobacco products? If so, which ones and how often?
Describe your caffeine/energy, drink/energy supplement habits
Describe your exercise habits
Describe your lifestyle
Describe your sleep habits
Describe your emotional state, moods, and behaviors. What makes you happy, stressed, or anxious?
How do you manage stress?
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Conclusion
What complaints / concerns do you have about your health and overall well-being?
What other questions or comments would you like to address?
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Appointment
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