ENROLLMENT FORM
Depending on insurance status, you may be required to complete additional forms
Contact
Part 1 of 6
Name
*
First Name
Last Name
If you have a Promo Code, include it below:
Phone Number
*
Please enter a valid phone number.
I agree to authorize the Tobacco Quitline to communicate with me by SMS text message on the number provided above (message/data rates may apply).
*
Please Select
I agree
I disagree
I do not have SMS text messaging capabilities
Are we allowed to leave a voice message?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age Range
*
Please Select
18-24
25-34
35-44
45-54
55-64
65+
What is your gender identity?
*
Please Select
Male
Female
Transgender
Nonconforming
Last 4 of Social Security Number
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Tell Us About Yourself
Part 2 of 6
Are you a West Virginia resident?
*
Please Select
Yes
No
Proof of residence
*
Please Select
WV Driver's License
State ID
Other
Primary language spoken
*
Please Select
English
Spanish
Other
Highest level of education completed
*
Please Select
Some High School
High School
GED
Some College
2 Year Degree
4 Year Degree
Graduate School
PhD
Which best describes you?
*
Please Select
African American
Asian
Caucasian
Hispanic
Other
Pregnancy/Nursing
*
Please Select
Pregnant
Thinking of becoming pregnant
Not pregnant
Nursing
Anticipated due date
-
Month
-
Day
Year
Date
Are you living with anyone who is pregnant?
Please Select
Yes
No
Do you have children?
Please Select
Yes
No
Do you belong to any of these special groups or fall into any of these categories?
*
LGBTQ
College Student
Active/Reserve/Retired Military
None of the above
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Insurance
Part 3 of 6
What type of insurance do you have?
*
Private insurance
Medicaid
Medicare
None
Who is your insurance provider?
*
E.G. PEIA
Medicaid Provider
*
Please Select
Unicare
Aetna Better Health
The Health Plan
WV Family Health
Traditional
Not sure
Medicaid number
*
Pharmacy Phone Number
Please enter a valid phone number.
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Tobacco Use
Part 4 of 6
What type or types of tobacco do you use?
*
Cigarettes
Cigars, little cigars or cigarillos
Pipe
Snuff
Snus
Other (E.G. Bidis)
How many packs of cigarettes per day?
*
Please Select
Half a pack (up to 10 cigarettes)
1 pack
1.5 packs
2 packs
3 packs
4 packs
5 or more packs
How soon after you wake up do you smoke your first cigarette?
*
Please Select
Within 5 minutes
6 to 30 minutes
31-60 minutes
After 60 minutes
Do you find it difficult to refrain from smoking in places where it is forbidden, eg church libraries movies etc?
*
Yes
No
Which cigarette would you hate the most to give up?
*
First one in the morning
All others
How many cigarettes do you smoke per day?
*
Please Select
10 or less
11-20
21-30
31 or more
Do you smoke more frequently during the first hours after waking up than during the rest of the day?
*
Yes
No
Do you smoke if you are so ill that you are in bed most of the day?
*
Yes
No
Are you a user of menthol cigarettes?
*
Yes
No
How many cans of snuff per day?
*
Please Select
Half a can
1 can
2 cans
3 cans
4 cans
5 cans
How many cans of snus per day?
*
Please Select
Half a can
1 can
2 cans
3 cans
4 cans
5 cans
Do you currently use an E-Cigarette/Vapor/Electronic nicotine delivery system?
*
Please Select
Yes
No
On a scale of 1-10, how confident are you in your quit attempt?
*
No Confidence
1
2
3
4
5
6
7
8
9
Highest Confidence
10
1 is No Confidence, 10 is Highest Confidence
On a scale of 1-10, how motivated are you to quit?
*
No Motivation
1
2
3
4
5
6
7
8
9
Highest Motivation
10
1 is No Motivation, 10 is Highest Motivation
Do you intend to quit in the next 30 days?
*
Please Select
Yes
No
When do you see yourself quitting?
*
Please Select
Within 1 week
Within 1 month
Within 6 months
Already taken action to quit
Already taken action to quit within 1 week
Action taken within 1 month
Action taken within 6 months
I'm not planning to quit
I don't know
ASAP
Are you committed to communicating with the Quitline coaches to provide you support during the quitting process?
*
Please Select
Yes
No
How often do you use tobacco?
*
Please Select
Everyday
Some days
Not at all
How soon after you wake up do you use tobacco?
*
Please Select
Within 5 minutes
6-30 minutes
31-60 minutes
More than an hour
I don't know
Refused
How old were you when you first started regularly using tobacco?
*
Total years used?
*
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Tobacco Use (Continued)
Part 5 of 6
Do you live with other tobacco users?
Please Select
Yes
No
Do you have a tobacco use policy in your home?
Please Select
Yes
No
Do you socialize with other tobacco users?
Please Select
Yes
No
Do you work with other tobacco users?
Please Select
Yes
No
Are you interested in using Nicotine Replacement Therapy to help you quit?
*
Please Select
Yes
No
Have you previously tried using Nicotine Replacement Therapy to help you quit?
*
Please Select
Yes
No
Have you ever tried to quit?
*
Please Select
Yes
No
How many times have you seriously tried to quit?
Please Select
I don't know
Refused
1
2
3
4
5
6
7
8
9
10+
How long ago was your last attempt?
*
How long did you maintain your last attempt to quit?
*
What methods did you use in your last attempt to quit?
*
Nicotine replacement: Patch
Nicotine replacement: Gum
Nicotine replacement: Spray
Nicotine replacement: Inhaler
Nicotine replacement: Lozenges
Group Program
Cold Turkey
Medications
I've never tried to quit
Why do you think you were not successful in your last attempt to quit?
*
Stress/Nerves
Lack of motivation
Wasn't really ready
Enjoyed it too much
Weight management issues
Cost of pharmaceuticals
Boredom
No longer pregnant
Needed more help
I've never tried to quit
Why are you currently interested in quitting?
*
Personal health related reasons
Family/friend support
Family/friend pressure
Physician pressure
Financial reasons
Personal goal
Reduce premiums/premium benefits
Pregnant
For the children
Tired of it
It's a bad habit
Death of a loved one
Not currently interested in quitting
Where did you hear about the Quitline?
*
Please Select
Newspaper
Radio
Television
Flyer/Brochure
Billboard
Health Professional
Internet
Phone Directory
Family/Friends
Employer
Health Insurance
Community Organization
Unknown/Refused
During the last 3 months, have you seen television commercials featuring people talking about their health problems as a result of their smoking?
*
Yes
No
Have you already taken action to quit?
*
Please Select
Yes
No
Have you spoken to your physician about your quit attempt?
*
Please Select
Yes
No
Do you have a person or group to support you through your quit attempt?
*
Please Select
Yes
No
Do you have any behavioral health conditions such as anxiety, depression, or bipolar?
*
Yes
No
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Finishing Up!
Part 6 of 6
I am requesting (one only)
*
Patches
Gum
Lozenges
The West Virginia Tobacco Quitline wants to be sure that you can use nicotine replacement products safely. Listed below are concerns that we and your physician need to know if you want to use nicotine replacement products. Please check any and all of the conditions that apply to you.
*
I am pregnant
I have had a recent heart attack (within 2 weeks)
I have an irregular heart beat
None of the above apply to me
Type your initials after each of these statements to agree:
1. I agree to stop using nicotine replacement products and see my doctor if I become pregnant while using quit tobacco products.
*
2. I agree to stop using nicotine replacement products and see my physician if side effects that do not go away after 4 days.
*
3. I agree to stop using nicotine replacement products if I develop an irregular heartbeat.
*
Do you currently use JUUL?
Yes
No
Would you like to learn more about participating in a research study for smoking cessation?
Yes
No
Submit
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