Tell Us A Little About You
How did your hear about our program?
Select Option Family/Friend TV Maine QuitLink Website Other Website Social Media Provider Employer Other I Don’t Know Prefer Not To Say
Are you active service or a veteran from any branch of the US Military, including the National Guard or Reserves? Select Option Yes, Active Yes, Veteran No Prefer Not To Say
What is the highest level of education you have completed? Select Option Less Than Grade 9 Grade 9-11 No Degree GED High School Degree Some College or University Some Technical/Trade School Technical/Trade School degree I Don’t Know
What terms best describe your sexual identity? Select Option Female Male Transgender Female Transgender Male Does Not Identify as Female, Male or Transgender Other
If you are female and age 50 or younger: Are you currently pregnant, planning a pregnancy in the next few months, or postpartum within 12 months? Select Option Not Pregnant Currently Pregnant Planning Pregnancy in Next 3 Months Postpartum within 12 Months Prefer Not To Answer
Have you been diagnosed with any of the following chronic conditions?
(Check all that apply) Asthma Cancer Chronic Bronchitis (COPD or CLRD) Coronary Artery Disease (CAD) Heart Failure (CHF) Stroke Pre-Diabetes/Diabetes None I Don’t Know Prefer Not To Say
Do you have any known behavioral health conditions such as anxiety, depression, bipolar disorder, schizophrenia, substance use disorder, ADHD, or PTSD? Select Option Yes No I Don’t Know Prefer Not To Say
If yes, based on your answer do you think it will be more difficult for you to quit?
Select Option Yes No I Don't Know
What is your health plan or health insurance? This service, including medication support, is free regardless of this answer. We are asking to better understand the reach of our program Select Option I Don’t Have Insurance MaineCare Medicare Commercial I Don’t Know