|
<html>
<head>
<title>Evaluation Form</title>
</head>
<body leftmargin="170" rightmargin="120" BACKGROUND="Swurvey.jpg">
<FORM METHOD="POST" ACTION="http://12.109.56.37/cgi-bin/FormMail.pl">
<CENTER> <IMG SRC="StopSmokingClinicEvaluation.gif" Width="200" Height="150"> <BR>
<IMG SRC="mgbarj2.jpg" width="497" height="29"> <BR>
<FONT COLOR="FF0000"> <U>
Please select 1 through 5 as these statements relate to you. 1 being never, 3 being sometimes, and 5 being always. </U> </FONT> <P>
</CENTER>
A. I smoke to keep myself from slowing down. <SELECT NAME="A" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
B. Handling a cigarette is part of the enjoyment of smoking it. <SELECT NAME="B" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
C. Smoking cigarettes is pleasant and relaxing. <SELECT NAME="C" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
D. I light up a cigarette when I feel angry about something. <SELECT NAME="D" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
E. When I run out of cigarettes, I find it almost unbearable untill I can get more. <SELECT NAME="E" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
F. I smoke automatically without even being aware of it. <SELECT NAME="F" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
G. I smoke when I am by myself. <SELECT NAME="G" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
H. I smoke cigarettes to stimulate me, to perk myself up. <SELECT NAME="H" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
I. Part of the enjoyment of smoking a cigarette comes from the steps I take to light up. <SELECT NAME="I" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
J. I find cigarettes pleasurable. <SELECT NAME="J" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
K. When I feel upset, I light up a cigarette. <SELECT NAME="K" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
L. When I am not smoking, I am very much aware of the fact. <SELECT NAME="L" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
M. I light up a cigarette without realizing I still have one burning in the ashtray. <SELECT NAME="M" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
N. I smoke when driving to keep busy. <SELECT NAME="N" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
O. I smoke cigarettes to give me a "lift". <SELECT NAME="O" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
P. When I smoke a cigarette, part of the enjoyment is watching the smoke as I exhale it. <SELECT NAME="P" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
Q. I want a cigarette most when I am comfortable and relaxed. <SELECT NAME="Q" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
R. When I feel "blue" or want to take my mind off cares and worries, I smoke a cigarette. <SELECT NAME="R" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
S. I get a real gnawing hunger for a cigarette when I haven't smoke for a while. <SELECT NAME="S" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
T. I have found a cigarette in my mouth and did not remember putting it there. <SELECT NAME="T" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
U. I smoke cigarettes when I have nothing to do. <SELECT NAME="U" Size="1" ALIGN="right"> <OPTION SELECTED>--
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
</SELECT> </ALIGN>
<P>
<FONT COLOR="FF0000"> Please fill out all information below accordingly.
</FONT>
<P> <BR> <P> <BR> <P>
<TABLE CELLSPACING="5" width="573">
<TR>
<TD ALIGN="left" width="557">
<FIELDSET WIDTH="375"> <LEGEND> Name and Contact Information </LEGEND>
First:<INPUT TYPE="text" NAME="First" SIZE="30"> Last:
<INPUT TYPE="text" NAME="Last" SIZE="35"> <P>
Birthday: <SELECT NAME="Month" Size="1">
<OPTION SELECTED>--
<OPTION>January
<OPTION>Febuary
<OPTION>March
<OPTION>April
<OPTION>May
<OPTION>June
<OPTION>July
<OPTION>August
<OPTION>September
<OPTION>October
<OPTION>November
<OPTION>December
</SELECT>
/
<SELECT NAME="Day" Size="1">
<OPTION SELECTED>--
<OPTION>01
<OPTION>02
<OPTION>03
<OPTION>04
<OPTION>05
<OPTION>06
<OPTION>07
<OPTION>08
<OPTION>09
<OPTION>10
<OPTION>11
<OPTION>12
<OPTION>13
<OPTION>14
<OPTION>15
<OPTION>16
<OPTION>17
<OPTION>18
<OPTION>19
<OPTION>20
<OPTION>21
<OPTION>22
<OPTION>23
<OPTION>24
<OPTION>25
<OPTION>26
<OPTION>27
<OPTION>28
<OPTION>29
<OPTION>30
<OPTION>31
</SELECT>
/
<SELECT NAME="Year" Size="1">
<Option selected>--
<OPTION>2002
<OPTION>2001
<OPTION>2000
<OPTION>1999
<OPTION>1998
<OPTION>1997
<OPTION>1996
<OPTION>1995
<OPTION>1994
<OPTION>1993
<OPTION>1992
<OPTION>1991
<OPTION>1990
<OPTION>1989
<OPTION>1988
<OPTION>1987
<OPTION>1986
<OPTION>1985
<OPTION>1984
<OPTION>1983
<OPTION>1982
<OPTION>1981
<OPTION>1980
<OPTION>1979
<OPTION>1978
<OPTION>1976
<OPTION>1975
<OPTION>1974
<OPTION>1973
<OPTION>1972
<OPTION>1971
<OPTION>1970
<OPTION>1969
<OPTION>1968
<OPTION>1967
<OPTION>1966
<OPTION>1965
<OPTION>1964
<OPTION>1963
<OPTION>1962
<OPTION>1961
<OPTION>1960
<OPTION>1959
<OPTION>1958
<OPTION>1957
<OPTION>1956
<OPTION>1955
<OPTION>1954
<OPTION>1953
<OPTION>1952
<OPTION>1951
<OPTION>1950
<OPTION>1949
<OPTION>1948
<OPTION>1947
<OPTION>1946
<OPTION>1945
<OPTION>1944
<OPTION>1943
<OPTION>1942
<OPTION>1941
<OPTION>1940
<OPTION>1939
<OPTION>1938
<OPTION>1937
<OPTION>1936
<OPTION>1935
<OPTION>1934
<OPTION>1933
<OPTION>1932
<OPTION>1931
<OPTION>1930
<OPTION>1929
<OPTION>1928
<OPTION>1927
<OPTION>1926
<OPTION>1925
<OPTION>1924
<OPTION>1923
<OPTION>1922
<OPTION>1921
<OPTION>1920
<OPTION>1919
<OPTION>1918
<OPTION>1917
<OPTION>1916
<OPTION>1915
<OPTION>1914
<OPTION>1913
<OPTION>1912
<OPTION>1911
<OPTION>1910
<OPTION>1909
<OPTION>1908
<OPTION>1907
<OPTION>1906
<OPTION>1905
<OPTION>1904
<OPTION>1903
<OPTION>1902
<OPTION>1901
<OPTION>1900
</SELECT>
SS#: <INPUT TYPE="TEXT" NAME="SS1" SIZE="3"> - <INPUT TYPE="TEXT" NAME="SS2" SIZE="2"> - <INPUT TYPE="TEXT" NAME="SS3" SIZE="4">
<P>
Address: <INPUT TYPE="TEXT" NAME="Address" SIZE="70"> <P>
City: <INPUT TYPE="TEXT" NAME="City" Size="30"> State: <SELECT NAME="State" Size="1">
<OPTION SELECTED>--
<OPTION>AL
<OPTION>AK
<OPTION>AZ
<OPTION>AR
<OPTION>CA
<OPTION>CO
<OPTION>CT
<OPTION>DE
<OPTION>FL
<OPTION>GA
<OPTION>HI
<OPTION>ID
<OPTION>IL
<OPTION>IN
<OPTION>IA
<OPTION>KA
<OPTION>KY
<OPTION>LA
<OPTION>ME
<OPTION>MD
<OPTION>MA
<OPTION>MI
<OPTION>MN
<OPTION>MS
<OPTION>MO
<OPTION>MT
<OPTION>NE
<OPTION>NV
<OPTION>NH
<OPTION>NJ
<OPTION>NY
<OPTION>NC
<OPTION>ND
<OPTION>OH
<OPTION>OK
<OPTION>OR
<OPTION>PA
<OPTION>RI
<OPTION>SC
<OPTION>SD
<OPTION>TN
<OPTION>TX
<OPTION>UT
<OPTION>VT
<OPTION>VA
<OPTION>WA
<OPTION>WV
<OPTION>WI
</SELECT>
Zip: <INPUT TYPE="text" NAME="Zip" SIZE="5">
<P>
Phone Number: <INPUT TYPE="text" Name="Home" SIZE="14"> Cell Phone: <INPUT TYPE="text" Name="Cell" SIZE="14"> <BR> <BR>
E-Mail Address: <INPUT TYPE="TEXT" Name="email" SIZE="30"> <BR>
</FIELDSET>
</TD>
</TR>
</TABLE>
<TABLE CELLSPACING="5" width="579">
<TR>
<TD ALIGN="left" width="563">
<FIELDSET WIDTH="375"> <LEGEND> Work Information </LEGEND>
Employer: <INPUT TYPE="TEXT" Name="Employer" SIZE="30"> Phone Number: <INPUT TYPE="TEXT" NAME="Work" SIZE="14"> <BR>
Home Page: <INPUT TYPE="TEXT" NAME="WorkWeb" SIZE="30"> E-Mail: <INPUT TYPE="TEXT" NAME="WorkMail" SIZE="20"> <BR> <BR>
Street: <INPUT TYPE="TEXT" NAME="WkSt" SIZE="73"> <P>
City: <INPUT TYPE="TEXT" NAME="WkCity" SIZE="30"> State: <SELECT NAME="WkState" Size="1">
<OPTION SELECTED>--
<OPTION>AL
<OPTION>AK
<OPTION>AZ
<OPTION>AR
<OPTION>CA
<OPTION>CO
<OPTION>CT
<OPTION>DE
<OPTION>FL
<OPTION>GA
<OPTION>HI
<OPTION>ID
<OPTION>IL
<OPTION>IN
<OPTION>IA
<OPTION>KA
<OPTION>KY
<OPTION>LA
<OPTION>ME
<OPTION>MD
<OPTION>MA
<OPTION>MI
<OPTION>MN
<OPTION>MS
<OPTION>MO
<OPTION>MT
<OPTION>NE
<OPTION>NV
<OPTION>NH
<OPTION>NJ
<OPTION>NY
<OPTION>NC
<OPTION>ND
<OPTION>OH
<OPTION>OK
<OPTION>OR
<OPTION>PA
<OPTION>RI
<OPTION>SC
<OPTION>SD
<OPTION>TN
<OPTION>TX
<OPTION>UT
<OPTION>VT
<OPTION>VA
<OPTION>WA
<OPTION>WV
<OPTION>WI
</SELECT>
Zip: <INPUT TYPE="TEXT" NAME="WkZip" SIZE="5"> <BR> <BR>
Position Held: <INPUT TYPE="TEXT" NAME="Position" SIZE="30">
Length of Employment: <BR> <BR> From-<SELECT NAME="WkMonth1" Size="1">
<OPTION SELECTED>--
<OPTION>January
<OPTION>Febuary
<OPTION>March
<OPTION>April
<OPTION>May
<OPTION>June
<OPTION>July
<OPTION>August
<OPTION>September
<OPTION>October
<OPTION>November
<OPTION>December
</SELECT>
/
<SELECT NAME="WkYear1" Size="1">
<Option selected>--
<OPTION>2002
<OPTION>2001
<OPTION>2000
<OPTION>1999
<OPTION>1998
<OPTION>1997
<OPTION>1996
<OPTION>1995
<OPTION>1994
<OPTION>1993
<OPTION>1992
<OPTION>1991
<OPTION>1990
<OPTION>1989
<OPTION>1988
<OPTION>1987
<OPTION>1986
<OPTION>1985
<OPTION>1984
<OPTION>1983
<OPTION>1982
<OPTION>1981
<OPTION>1980
<OPTION>1979
<OPTION>1978
<OPTION>1976
<OPTION>1975
<OPTION>1974
<OPTION>1973
<OPTION>1972
<OPTION>1971
<OPTION>1970
<OPTION>1969
<OPTION>1968
<OPTION>1967
<OPTION>1966
<OPTION>1965
<OPTION>1964
<OPTION>1963
<OPTION>1962
<OPTION>1961
<OPTION>1960
<OPTION>1959
<OPTION>1958
<OPTION>1957
<OPTION>1956
<OPTION>1955
<OPTION>1954
<OPTION>1953
<OPTION>1952
<OPTION>1951
<OPTION>1950
<OPTION>1949
<OPTION>1948
<OPTION>1947
<OPTION>1946
<OPTION>1945
<OPTION>1944
<OPTION>1943
<OPTION>1942
<OPTION>1941
<OPTION>1940
<OPTION>1939
<OPTION>1938
<OPTION>1937
<OPTION>1936
<OPTION>1935
<OPTION>1934
<OPTION>1933
<OPTION>1932
<OPTION>1931
<OPTION>1930
<OPTION>1929
<OPTION>1928
<OPTION>1927
<OPTION>1926
<OPTION>1925
<OPTION>1924
<OPTION>1923
<OPTION>1922
<OPTION>1921
<OPTION>1920
<OPTION>1919
<OPTION>1918
<OPTION>1917
<OPTION>1916
<OPTION>1915
<OPTION>1914
<OPTION>1913
<OPTION>1912
<OPTION>1911
<OPTION>1910
<OPTION>1909
<OPTION>1908
<OPTION>1907
<OPTION>1906
<OPTION>1905
<OPTION>1904
<OPTION>1903
<OPTION>1902
<OPTION>1901
<OPTION>1900
</SELECT>
To-<SELECT NAME="WkMonth2" Size="1">
<OPTION SELECTED>Present
<OPTION>January
<OPTION>Febuary
<OPTION>March
<OPTION>April
<OPTION>May
<OPTION>June
<OPTION>July
<OPTION>August
<OPTION>September
<OPTION>October
<OPTION>November
<OPTION>December
</SELECT>
/
<SELECT NAME="WkYear2" Size="1">
<Option selected>Present
<OPTION>2002
<OPTION>2001
<OPTION>2000
<OPTION>1999
<OPTION>1998
<OPTION>1997
<OPTION>1996
<OPTION>1995
<OPTION>1994
<OPTION>1993
<OPTION>1992
<OPTION>1991
<OPTION>1990
<OPTION>1989
<OPTION>1988
<OPTION>1987
<OPTION>1986
<OPTION>1985
<OPTION>1984
<OPTION>1983
<OPTION>1982
<OPTION>1981
<OPTION>1980
<OPTION>1979
<OPTION>1978
<OPTION>1976
<OPTION>1975
<OPTION>1974
<OPTION>1973
<OPTION>1972
<OPTION>1971
<OPTION>1970
<OPTION>1969
<OPTION>1968
<OPTION>1967
<OPTION>1966
<OPTION>1965
<OPTION>1964
<OPTION>1963
<OPTION>1962
<OPTION>1961
<OPTION>1960
<OPTION>1959
<OPTION>1958
<OPTION>1957
<OPTION>1956
<OPTION>1955
<OPTION>1954
<OPTION>1953
<OPTION>1952
<OPTION>1951
<OPTION>1950
<OPTION>1949
<OPTION>1948
<OPTION>1947
<OPTION>1946
<OPTION>1945
<OPTION>1944
<OPTION>1943
<OPTION>1942
<OPTION>1941
<OPTION>1940
<OPTION>1939
<OPTION>1938
<OPTION>1937
<OPTION>1936
<OPTION>1935
<OPTION>1934
<OPTION>1933
<OPTION>1932
<OPTION>1931
<OPTION>1930
<OPTION>1929
<OPTION>1928
<OPTION>1927
<OPTION>1926
<OPTION>1925
<OPTION>1924
<OPTION>1923
<OPTION>1922
<OPTION>1921
<OPTION>1920
<OPTION>1919
<OPTION>1918
<OPTION>1917
<OPTION>1916
<OPTION>1915
<OPTION>1914
<OPTION>1913
<OPTION>1912
<OPTION>1911
<OPTION>1910
<OPTION>1909
<OPTION>1908
<OPTION>1907
<OPTION>1906
<OPTION>1905
<OPTION>1904
<OPTION>1903
<OPTION>1902
<OPTION>1901
<OPTION>1900
</SELECT>
</FIELDSET>
</TD>
</TR>
</TABLE>
<TABLE CELLSPACING="5">
<TR>
<TD ALIGN="left">
<FIELDSET WIDTH="375"> <LEGEND> Personal Information </LEGEND>
Marital Status: <SELECT NAME="MaritalStatus" SIZE="1">
<OPTION SELECTED>Single
<OPTION>Married
<OPTION>Divorced
<OPTION>Widowed
<OPTION>Seperated
</SELECT>
Spouses Name: <INPUT TYPE="TEXT" NAME="SpousesName" SIZE="15"> <BR> <BR>
Are you currently having problems (at home, job, financial, etc)? <BR> Home <INPUT TYPE="checkbox" NAME="Problems" VALUE="Home"> Work<INPUT TYPE="checkbox" NAME="Problems?" VALUE="Work"> Financial<INPUT TYPE="checkbox" NAME="Problems?" VALUE="Financial"> Other<INPUT TYPE="checkbox" NAME="Problems?" VALUE="Other"> Please specify: <BR> <TEXTAREA Name="Problems?" ROWS="6" COLS="50"> </TEXTAREA> <P>
Are these problems serious or merely frustrating? <SELECT NAME="Serious" SIZE="1"> <OPTION SELECTED>Serious
<OPTION>Frustrating
<OPTION>Both
<OPTION>N/A
</SELECT><P>
How did you hear of our program? <SELECT NAME="Hear" SIZE="1"> <OPTION SELECTED>--
<OPTION>XL102
<OPTION>107.3
<OPTION>Other Radio
<OPTION>Yellow Pages
<OPTION>Web Search
<OPTION>Other Website
<OPTION>Friend
</SELECT>
<P>
List Hobbies: <BR> <TEXTAREA NAME="Hobbies" ROWS="6" COLS="50"> </TEXTAREA> <P>
Have you ever been treated for: <P> Heart Problems<INPUT TYPE="checkbox" NAME="Treated" VALUE="Heart Problems"> Drug Addiction<INPUT TYPE="checkbox" NAME="Treated" VALUE="Drug Addiction"> Cancer<INPUT TYPE="checkbox" NAME="Treated" VALUE="Cancer"> Mental-illness<INPUT TYPE="checkbox" NAME="Treated" VALUE="Mental-illness"> <BR> Alcohol<INPUT TYPE="checkbox" NAME="Treated" VALUE="Alcohol"> Emphysema<INPUT TYPE="checkbox" NAME="Treated" VALUE="Emphysema"> <P>
Do you have any of these now? <SELECT NAME="Haveanyofthese" SIZE="1">
<OPTION SELECTED>N/A
<OPTION>Yes
<OPTION>No
</SELECT>
Which ones? <P>
Heart Problems<INPUT TYPE="checkbox" NAME="WhichOnes" VALUE="Heart Problems2"> Drug Addiction<INPUT TYPE="checkbox" NAME="WhichOnes" VALUE="Drug Addiction2"> Cancer<INPUT TYPE="checkbox" NAME="WhichOnes" VALUE="Cancer2"> Mental-illness<INPUT TYPE="checkbox" NAME="WhichOnes" VALUE="Mental-illness2"> <BR> Alcohol<INPUT TYPE="checkbox" NAME="WhichOnes" VALUE="Alcohol2"> Emphysema<INPUT TYPE="checkbox" NAME="WhichOnes" VALUE="Emphysema2"> <P>
Do you drink liquor? <SELECT NAME="Liquor" SIZE="1"> <OPTION SELECTED>--
<OPTION>Yes
<OPTION>No
</SELECT>
Beer? <SELECT NAME="Beer" Size="1"> <OPTION SELECTED>--
<OPTION>Yes
<OPTION>No
</SELECT>
How often? <SELECT NAME="Frequency" SIZE="1"> <OPTION SELECTED>N/A
<OPTION>Rarely
<OPTION>Occasionaly
<OPTION>Social Drinker
<OPTION>A few a day
<OPTION>All the time
</SELECT>
<P>
Are you presently taking medication? <SELECT NAME="Medication" SIZE="1"> <OPTION SELECTED>--
<OPTION>Yes
<OPTION>No
</SELECT>
For what ailments? <BR> <TEXTAREA NAME="Ailments" ROWS="6" COLS="50"> </TEXTAREA> <P>
How long have you smoked? (Nearest ammount in years.) <INPUT TYPE="TEXT" NAME="HowLong" SIZE="2"> <P> How much daily? <SELECT NAME="HowMuch" SIZE="1"> <OPTION SELECTED>--
<OPTION HIDDEN>0
<OPTION>Less than a pack
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
<OPTION>6 or more
</SELECT>
Menthol or Regulars? <SELECT NAME="MR" SIZE="1"> <OPTION SELECTED>--
<OPTION>R
<OPTION>M
</SELECT> <P>
Present brand? <INPUT TYPE="TEXT" NAME="Brand" Size="10"> Filtered or Non? <SELECT NAME="Filtered" SIZE="1"> <OPTION SELECTED>Non
<OPTION>Filtered
</SELECT> <P>
Have you attempted to stop before? Yes<INPUT TYPE="radio" NAME="QuitBFour" VALUE="Yes"> No<INPUT TYPE="radio" NAME="QuitBFour" VALUE="No"> Number of times: <INPUT TYPE="TEXT" NAME"Times" SIZE="1"> <P>
Which Methods? (Check all that apply) <BR>
Cold Turkey<INPUT TYPE="checkbox" NAME="Methods" VALUE="ColdTurkey"> Cutting Down<INPUT TYPE="checkbox" NAME="Methods" VALUE="Cutdown"> Hypnosis<INPUT TYPE="checkbox" NAME="Methods" VALUE="Hypnosis"> Acupuncture<INPUT TYPE="checkbox" NAME="Methods" VALUE="Acupuncture"> <BR> Drugs<INPUT TYPE="checkbox" NAME="Methods" VALUE="Drugs"> Other<INPUT TYPE="TEXT" NAME="Methods" SIZE="40"> <P>
Do you by cigarettes by the Carton<INPUT TYPE="radio" NAME="Buyby" VALUE="Carton">, Pack<INPUT TYPE="radio" NAME="Buyby" VALUE="Pack">, or Both<INPUT TYPE="radio" NAME="Buyby" VALUE="Both">? <P>
How many Packs<INPUT TYPE="radio" NAME="PC" VALUE="Packs">/Cartons<INPUT TYPE="radio" NAME="PC" VALUE="Cartons"> per week? <INPUT TYPE="TEXT" NAME="howmany" SIZE="2"> <P>
How much do you usually spend for cigarettes? $<INPUT TYPE="TEXT" NAME="TCost" SIZE="3"> <BR> (Per Carton<INPUT TYPE="radio" NAME="Cost" VALUE="Carton"> or Per Pack<INPUT TYPE="radio" NAME="Cost" VALUE="Pack">)
<P>
Is smoking affecting your health? <SELECT NAME="Affecting" SIZE="1"> <OPTION SELECTED>--
<OPTION>Yes
<OPTION>No
</SELECT>
In what ways?<INPUT TYPE="TEXT" NAME="Whatways" SIZE="15"> <P>
Why do you want to quit? <INPUT TYPE="TEXT" NAME="Why" SIZE="50"> <P>
How important is quitting to you? (Check all that apply to you.)<P>
A. Urgent<INPUT TYPE="checkbox" NAME="Important" VALUE="Urgent"> B. Matter of life and death<INPUT TYPE="checkbox" NAME="Important" VALUE="Life&Death"> C. Very Important<INPUT TYPE="checkbox" NAME="Important" VALUE="Very Important"> <BR> D. Doctor told me to quit<INPUT TYPE="checkbox" NAME="Important" VALUE="Dr."> E. Spouse wants me to quit<INPUT TYPE="checkbox" NAME="Important" VALUE="Spouse"> F. I was <BR> curious about this program<INPUT TYPE="checkbox" NAME="Important" VALUE="Curious"> G. I want to set a good example <BR> for others<INPUT TYPE="checkbox" NAME="Important" VALUE="Example"> H. I should quit but there's no rush<INPUT TYPE="checkbox" NAME="Important" VALUE="NoRush"> I. I want to quit <BR> but I am afraid to try<INPUT TYPE="checkbox" NAME="Important" VALUE="Afraid">
Why afraid? <BR> <TEXTAREA NAME="Afraid" ROWS="6" COLS="50"> </TEXTAREA> <P>
Since we can break your smoking habit in 5 days (If you are REALLY <BR> SERIOUS), will you faithfully follow all of our instructions for 5 days? <BR> <SELECT NAME="FollowInstructions" SIZE="1"> <OPTION SELECTED>--
<OPTION>Yes
<OPTION>No
</SELECT>
<P>
Are you available for therapy Mornings<INPUT TYPE="radio" NAME="Available" VALUE="Mornings">, Evenings<INPUT TYPE="radio" NAME="Available" VALUE="Evenings">, or Both<INPUT TYPE="radio" NAME="Available" VALUE="Both">? <P>
</FIELDSET>
</TD>
</TR>
</TABLE>
<INPUT TYPE="hidden" NAME="submitaddress" VALUE="MagnusSSC@yahoo.com">
<INPUT TYPE="hidden" NAME="recipient" VALUE="MagnusSSC@yahoo.com">
<FONT COLOR="FF0000"> <CENTER> <B> <U> YOU WILL NOT BE ACCEPTED FOR OUR PROGRAM <BR>
UNLESS WE FEEL WE CAN HELP YOU!! <BR> THANK YOU AND HAVE A GOOD DAY! </U> </B> </CENTER> </FONT>
<P>
<INPUT TYPE="submit"> <INPUT TYPE="reset">
</form>
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