Smoke Free Detroit Initiative

REGISTRATION

First Name: Last Name:
Address:
City: State: Zip:
Email Address:
Phone Number: Age: Date of Birth:
How Long Have You Been A Smoker?:
     
Survey Questions
1. How many packs of cigarettes do you smoke per day?
2. How many cigarette breaks do you take a day?
3. Do you smoke in your car? Yes   No
4. When at home, do you smoke inside or outside? Yes   No
5. Do you have children? Yes   No
6. If yes, do you smoke around your children/infants? Yes   No
7. Do you have trouble breathing? Yes   No
8. Have you tried to quit before? Yes   No
9. If yes, what methods have you used?
10. Do you smoke after every meal? Yes   No