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Quitting Nicotine Assessment
Your Personalized Quitting Journey Begins Here.
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1
Are you at least 21?
*
This field is required.
You have to be 21 in certain jurisdictions to consume nicotine, by clicking yes you acknowledge you are over 21.
YES
NO
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2
Are you interested in quitting nicotine?
*
This field is required.
Yes
No
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3
Do you smoke or vape?
*
This field is required.
Smoke
Vape
Both
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4
How many packs of cigarettes do you smoke in a day?
*
This field is required.
Pack = 20 cigarettes
Less than 1 Pack
1 Pack
2 Packs
3 Packs
4+ Packs
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5
How many pods do you vape in a day?
*
This field is required.
Pod = 59mg/mL of nicotine
Less than 1 Pod
1 Pod
2 Pods
3 Pods
4+ Pods
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6
How many time(s) have you tried to quit?
*
This field is required.
First Time
1 Time
2-3 Times
4+ Times
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7
What methods have you tried to quit with in the past?
*
This field is required.
Select all the options that apply to you.
Cold turkey
Over-the-counter quit-nicotine aids
Counseling
Prescription treatment
None/Other
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8
Then this program isn't for you!
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9
What do you want to discuss with your Freedom Pods Quit Coach?
*
This field is required.
Select as many as you like:
Handling triggers
Nicotine withdrawal
Setting a quit date
Treatment options
Support programs
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10
What are your top 3 reasons for quitting nicotine?
Reason 1
Reason 2
Reason 3
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11
When would you be willing to quit nicotine?
Right Now!
Next Week
This Month
In a Few Months
Next Year
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12
What do you want to learn about Freedom Pods?
*
This field is required.
Select as many as you like:
Nicotine and non-nicotine options
How Freedom Pods work
Smoking/vaping while using Freedom Pods
Side effects
Cost of Freedom Pods
None/other
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13
What's your email address?
*
This field is required.
We'll send you an email with the next steps.
example@example.com
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14
We need your age and location information to see which regulations apply to your jurisdiction:
*Your information will remain private and securely stored.
Country
State
Age
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15
How did you find the Freedom Pods Quit Assessment?
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16
Interested in quitting nicotine with Freedom Pods?
By submitting you're verifying that you are 21+.
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17
Tags
Todo
In Progress
Done
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