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Smoking Cessation Clinical Trial Eligibility Questionnaire
Answer the questions about your smoking habits and health history to help us assess study fit.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How many cigarettes do you smoke per day on average?
*
How long have you been smoking at this rate?
*
Are you interested in quitting smoking?
*
Yes
No
Unsure
Do you currently use any nicotine products other than cigarettes? (e.g., e-cigarettes, nicotine gum, patches, lozenges, etc.)
*
Yes
No
Have you experienced a major depressive episode in the last 3 months?
*
Yes
No
Have you been diagnosed with an alcohol or substance abuse disorder?
*
Yes
No
Have you ever been diagnosed with a mental health condition?
*
No
Depression
Anxiety
Other (please specify)
Are you currently receiving treatment (medication or therapy) for depression or anxiety?
*
Yes
No
Not applicable
If you have depression or anxiety, is your condition currently stable without treatment?
*
Yes
No
Not applicable
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Time to Call
Submit
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