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Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

Tell Us More About Yourself

All fields required All questions are required At least one selection is required
To enroll in the program, we need to get some information from you. The next several pages will ask you questions about you and your tobacco history. Once you have completed the questions, we will begin this journey together!

Do you have a history of any of the following? Check all that apply.
Emphysema, Chronic Bronchitis, or COPD
History of seizures
Heart disease, irregular heart rate, or angina
Heart attack within the last 12 months
Stroke within the last 12 months
High blood pressure
High blood pressure is controlled with medication
Skin condition (eczema, psoriasis, etc.) or allergies to adhesives
Use dentures or have sensitive gums

Thank you

Thank you for enrolling in the quitline. We’ll email you your enrollment details within a business day. We’re glad you’ve taken your first steps toward becoming tobacco free. To continue with your quit journey click here.