JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Tobacco Cessation Therapy
Sign in to Google
to save your progress.
Learn more
Name
Your answer
Email ID
Your answer
WhatsApp/ Mobile number
Your answer
Number of years for tobacco use
Your answer
Quantity of daily consumption
Less than 5 cigarettes
5-10 cigarettes
10-20 cigarettes
more than 20 cigarettes
Clear selection
If chewing tobacco, please mention the quantity
Your answer
Motivation to stop/ control tobacco
Health reasons
Addiction
Compulsion from family
Other:
Clear selection
Where did you hear about us? (If referred by someone, please add the name in the last input)
Instagram/ Facebook
Advertisements
Webinars
Youtube
Other:
Clear selection
Please accept the TERMS & Conditions and submit
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
