Last Updated: 06/24/2009
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SMOKEFREE PHILLY: LOOK GOOD FEEL GOOD
SmokeFree Philly would appreciate your taking the time to complete the following survey to let us know something about yourself so that we can make sure the website is of interest to you. Of course, anything you share with us will remain confidential.

1. Are you a first time visitor to SmokeFreePhilly.org?
Yes No Don’t Remember

2. How did you first find SmokeFreePhilly.org?

Other:

3. During the past 30 days, on how many days did you smoke?

4. During the past 30 days, on how many days did you use tobacco other than cigarettes?

5. On most days, about how many cigarettes do you smoke? cigarettes

6. If you used to smoke, how many cigarettes did you smoke most days? cigarettes

7. If you used to smoke, how long ago did you quit?
(specify Weeks/Months/Years)

8. If you have stopped smoking, what did you use to help you?
(please check all that apply)
Stop smoking classes
Individual counseling
Medications (such as Chantix, Wellbutrin or Zyban)
Nicotine replacement therapy (such as the patch, gum or lozenge)
Going Cold Turkey
Other

9. Who in your home (other than yourself) uses tobacco now?
(please check all that apply)
No one
Spouse/ partner
Parent(s)
Sister/brother
Roommate
Child/children
Other

10. Which of these groups best describes you?

11. What is your zip code?
(If you are outside the U.S., please enter the name of your country)

12. What is your age?

13. What is your gender?

14. What is the last level of school that you have completed?

Please leave your questions, suggestions and comments about the website on our contact form. Thank you for your time!