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113年「無菸無慮 健康人生」社區成人戒菸班報名表
主辦單位：連江縣衛生局、連江縣立醫院
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姓名
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性別
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男
女
出生年月日
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MM
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DD
/
YYYY
聯絡電話
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吸菸習慣（每天抽幾隻）
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31支以上
21-31支
11-20支
10隻或更少
菸齡（抽菸抽幾年）
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備註
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