Quit Tobacco and Nicotine! We can help.
Smoking Cessation and Nicotine Replacement Therapy Questionnaire
Follow the link at the bottom of the page to make an appointment with the pharmacist.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Required: Please answer the following smoking and smoking cessation related questions.
Have you tried to quit smoking before?
*
Yes
No
If you have tried to quit before, what types of therapies did you use to help?
*
Nicotine gum or lozenges
Nicotine patches
Oral medication such as Chantix (Varenicline) or Wellbutrin (Bupropion)
Nicotine Inhaler or nasal spray
None (aka cold turkey)
Other
When do you usually have your first cigarette or use nicotine products?
*
Within 30 minutes after waking up
More than 30 minutes after waking up
Approximately how many cigarettes do you smoke per day? If you use a different type of nicotine product (such as a vape), how often do you use it?
*
Select your preference for a type of nicotine replacement therapy?
*
Gum
Lozenge
Patch
Combination of patches and gum/lozenge
Nicotine inhaler or nasal spray
Oral medication (Note: This will require a prescription from your primary care provider but we will assist in getting this for you if you are a good candidate for it.)
No preference
List all of your medication and food allergies. If none, write none.
*
Are you pregnant or could become pregnant?
*
Yes
No
Have you had a heart attack in the past 2 weeks?
*
Yes
No
Do you have a history of heart palpitations, irregular heartbeats, or have you been diagnosed with serious arrhythmia?
*
Yes
No
Do you have a history of allergic rhinitis (hay fever)?
*
Yes
No
Have you been diagnosed with temporomandibular joint (TMJ) dysfunction?
*
Yes
No
Please list the names of all of the prescription, over-the-counter and herbal medications that you take. You do NOT need to provide dosing.
*
Submit
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