Home»Enregistrer Congratulations on making the decision to put your wellness first and become tobacco free! Please tell us a bit about yourself. This should only take about 5 minutes. E-mail* Username* Usernames cannot be changed. Password* Type your password. The password must have a minimum strength of MediumStrength indicator Repeat Password* Type your password again. Date of Birth* Gender*MaleFemaleTransgenderContact Information First Name* Phone Number* Required phone number format: (###) ###-####, Standard, Standard Address* City* Province, Country* Postal Code* 1. Do you currently smoke cigarettes? *DailyOccasionally (less than 7 days per week or less than 1 cigarette per day)Not at all 2. When was your last cigarette? *Less than 24 hours agoMore than 24 hours ago 3. How many cigarettes do you or did you smoke on the days that you smoke?* 4. At what age did you start smoking regularly?* 5. How many times have you tried to quit smoking where an attempt has lasted longer than 1 day?* 6. How many members of your household smoke cigarettes?* 7. About how much does or did a pack of cigarettes cost you? Ex. $6.50* 8. How many cigarettes are in the packs you buy or bought?* 1. How soon after waking do you smoke your first cigarette?*Within 5 minutes (3 points)5-30 minutes (2 points)31-60 minutes (1 point) 2. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g. church, library, etc.?*Yes (1 point)No (0 points) 3. Which cigarette would you hate to give up?*The first in the morning (1 point)Any other (0 points) 4. How many cigarettes a day do you smoke?*10 or less (0 points)11-20 (1 point)21-30 (2 points)31 or more (3 points) 5. Do you smoke frequently in the morning?*Yes (1 point)No (0 points) 6. Do you smoke even if you are sick in bed most of the day?*Yes (1 point)No (0 points)