Phone Coaching | Maine QuitLink

1Residency

2Contact Information

3Tobacco or Nicotine Use

4Support Preferences

5Health & Background

6Optional Information

This field is for validation purposes and should be left unchanged.

Do you currently reside in Maine?*

Yes

First Name*

Last Name*

Date of Birth*

MM slash DD slash YYYY

Mailing Address*

Address Line 2 (optional)

City*

State*

Zip Code*

Phone Number*

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Best time of day to reach you during the week*

Anytime

Morning 8-12

Afternoon 12-4

Best time of day to reach you during the week*

Morning 8am – 12pm

Afternoon 12pm – 4pm

How soon after you wake up do you use tobacco or nicotine products?*

What tobacco and nicotine products do you currently use/have used in past 30 days? * (select all that apply)

Cigarettes

Please select how often you smoke*

Daily

Some days

I have already quit

Not sure

Prefer not to say

How many cigarettes per day do you/did you smoke?*

Please enter a number from 0 to 1000.

Do you smoke menthol cigarettes?*

Yes

Not sure

Prefer not to say

E-cigarette/Vaping products

Please select how often you vape*

Daily

Some days

I have already quit

I don’t know

I prefer not to say

Cigars or little cigars

Please select how often you smoke cigars/little cigars*

Daily

Some days

I have already quit

I don’t know

I prefer not to say

How many cigars/little cigars per day do you/did you smoke?*

Please enter a number from 1 to 1000.

Do you smoke menthol cigars or little cigars?*

Yes

Not sure

Prefer not to say

Spit, smokeless tobacco (chew), or pouches

Please select how often you use spit, smokeless tobacco (chew), or pouches*

Daily

Some days

I have already quit

I don’t know

I prefer not to say

Roughly how many tins or pouches do you use per week during the weeks you use tobacco?*

Please enter a number from 1 to 1000.

Pipe

Please select how often you smoke pipe?*

Daily

Some days

I have already quit

I don’t know

I prefer not to say

How many pipes per week do you smoke?*

Please enter a number from 1 to 1000.

Hookah or water pipe

Please select how often you use a hookah or water pipe?*

Daily

Some days

I have already quit

I don’t know

I prefer not to say

How many times per week do you use a hookah or water pipe?*

Please enter a number from 1 to 1000.

How did you hear about the Maine Quitlink?*

Have you worked with the Maine QuitLink in the past 12 months?*

Yes

I’m not sure

Are you currently using or interested in using nicotine patches, gum, lozenges (NRT) or a combination of these to help you quit?*

Yes, I am interested in using NRT

Yes, I am already using NRT and would like more

I’m not sure

I am NOT interested in using NRT

I prefer not to say

Tell us when you want to quit using tobacco and vape products. If you have already quit, please share your approximate quit date.

MM slash DD slash YYYY

Gender*

Male

Female

Non-binary

Transgender male

Transgender female

Not listed

I don’t know

I prefer not to say

If you are under 50, are you currently pregnant, planning on a pregnancy or have you given birth in the past 12 months?

Not pregnant

Currently pregnant

Planning a pregnancy

Postpartum within 12 months

I prefer not to say

Have you been diagnosed with any of the following health conditions?*

None of these

Asthma

Cancer

Heart failure (CHF)

Coronary Artery Disease (CAD)

Chronic bronchitis (COPD/Emphysema)

Pre-diabetes/diabetes

Stroke

I don’t know

I prefer not to say

Choose your health plan. This helps us know who our program is reaching. The service is free, no matter your answer.  *

Have you been diagnosed with any of the following behavioral health conditions such as anxiety, depression, bipolar disorder, schizophrenia, substance use disorder, ADHD, or PTSD?*

Yes

I don’t know

I prefer not to say

Based on your answer, do you think it will be more challenging to quit?*

Yes

I don’t know

I prefer not to say

What is the highest level of education you have completed?

Are you an active service or a veteran of any branch of the US Military, including National Guard or Reserves?

Yes-Retired

Yes-Active

I prefer not to say

Which best describes your race? Select all that apply.

White

Black or African American

Native American or Indigenous

Native Hawaiian or Other Pacific Islander

Not listed

I don’t know

I prefer not to say

Are you Hispanic or Latino?

Yes

I don’t know

I prefer not to say

What best describes your sexual orientation? Select all that apply.

Asexual

Bisexual

Gay or Lesbian

Heterosexual or Straight

Pansexual

Queer

Not listed

I don’t know

I prefer not to say

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