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Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

Tell Us More About Yourself

All fields required All questions are required At least one selection is required

To enroll in the program, we need to get some information from you. The next several pages will ask you questions about you and your tobacco history. Once you have completed the questions, we will begin this journey together!

* Required

Quit Partner needs to collect some personal information to provide you with free quit nicotine services. We will also use your information to help evaluate how well our programs work and for research. The information we are collecting about you is private under Minnesota state law. Your private information will only be shared with MDH, its vendors, the Centers for Disease Control and Prevention, and other people or entities as authorized by law. If your information is shared with other external partners for program evaluation or research purposes, your name and other information that could identify you will be removed.
You will be asked some required and optional questions. You do not have to answer any of these questions, but if you do not answer the required ones, you will not be able to receive services from Quit Partner. You may be able to receive services elsewhere.

In which program(s) would you like to participate? Please choose at least one of the following checkboxes:
Individuals who sign up for coaching and quit medications together are twice as likely to quit successfully.

Phone – Free coaching over the phone to develop a quit plan and get extra quit medications. Sign up for our standard program or learn more about our specialized programs for American Indians, people with behavioral health conditions, & pregnant/postpartum people.

Online – Sign up to get a starter kit of quit medications (two weeks), chat with a coach by using the live chat function, or design your quit plan. For the full coaching program, please select the phone option.

Nicotine Replacement Therapy – Check this box to get a starter kit of two weeks of a quit medications(patches, gum, lozenges) as part of your online program to help you quit.

Text - Sign up for motivational texts, quit medication updates, appointment reminders, and more. Message frequency will vary. Reply HELP for help. Reply STOP to stop (or cancel). Message and data rates may apply.

Email – Sign up for motivational emails, quit medication updates, appointment reminders, and more.

What is your preferred language?
English
Spanish
Other

Quit Partner offers a phone coaching program just for pregnant and postpartum people. If you are currently pregnant and would like to learn more about this program or enroll, call 1-800-QUIT-NOW.

Please enter your first name.

Please enter your last name.

What is your preferred phone number?

Please enter your zip code.

Please tell us when you were born.

Please enter your email address.

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Include a minimum of 8 characters, with at least 1 of each of the following: uppercase & lowercase characters, digits, and non-alphabetic characters (e.g. !, $, #, %)

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What tobacco product(s) are you currently using?

Cigarettes

Smokeless tobacco, chew tobacco, snuff, or dip

Cigars, cigarillos, or small cigars

Pipe with tobacco

None

Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?
Yes
No

Because of COVID-19, has your motivation to quit cigarettes increased, decreased or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer

Because of COVID-19, has the amount you smoke increased, decreased or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer

Do you smoke cigarettes every day or some days?
Every day
Some days

How soon after you wake, do you smoke your first cigarette?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Are the cigarettes you usually smoke menthol cigarettes?
Yes, I usually smoke menthol cigarettes
No, I usually smoke other types of cigarettes
Don't know
Refused

Quit Partner offers an incentive program for participants who complete phone coaching and use menthol tobacco. If you would like to learn more, call 1-800-QUIT-NOW.

Do you use chewing tobacco, snuff or dip every day or some days?
Every day
Some days

How many pouches or tins do you use per week, on the weeks that you use tobacco?

How soon after you wake, do you first use spit tobacco, snuff or chew?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Do you smoke cigars every day or some days?
Every day
Some days

How many cigars, cigarillos or little cigars do you smoke per week on the weeks that you smoke?

How soon after you wake, do you first smoke a cigar, cigarillo, or little cigar?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Do you smoke a pipe with tobacco every day or some days?
Every day
Some days

How many pipes do you smoke per week, on the weeks that you smoke?

How soon after you wake, do you first smoke a pipe?
Within five minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes

Because of COVID-19, has your motivation to quit e-cigs/Vaping increased, decreased or stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer

Because of COVID-19, has the amount you use e-Cigs or vape increased, decreased, stayed the same?
Increased
Decreased
Stayed the same
Don't know
Prefer not to answer

How many days did you use an e-cigarette or electronic “vaping” product in the last 30 days?

Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?
Yes
No

Participant feedback helps us improve our services. Providing feedback is voluntary and does not impact your participation in the program. You can choose what you want to share and when you want to share it. After you complete the program, may we contact you about your experience?
Yes
No

Disclaimer : We do not provide medical care. Talk to your doctor about your plan to quit tobacco and use of nicotine replacement or other quit smoking medicine if you have any questions or problems.
Read Disclaimer? Yes

Do you have a history of any of the following? Check all that apply.

None

Asthma

Emphysema, Chronic Bronchitis, or COPD

History of seizures

Diabetes

Cancer

Heart disease, irregular heart rate, or angina

Heart attack within the last 12 months

Stroke within the last 12 months

High blood pressure

High blood pressure is controlled with medication

Skin condition (eczema, psoriasis, etc.) or allergies to adhesives

Use dentures or have sensitive gums

Currently pregnant Yes No

Due Date?

Currently breastfeeding Yes No

Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?

Which of these groups would you say best describes you?

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino/Latina

Native Hawaiian or Pacific Islander

White

Do you consider yourself to be gay, lesbian, bisexual and/or queer?
Yes
No

Bisexual

Gay or lesbian

Queer

What is the highest level of education you have completed?
Less than grade 9
Grade 9 to 11, no degree
GED (General Educational Development)
High school degree
Some college or university (includes some technical or trade school)
College or university degree (includes AA, BA, Masters, and PH.D.)

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Tell Us About Yourself

Medical Conditions

Tell Us More About Yourself

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