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First Name:
Last Name:
Email:
Age:
Sex:
How long have you been smoking?
What do you smoke i.e. cigarettes, cigars, roll ups?
How many do you smoke a day?
Why did you start smoking?
What do you gain from smoking?
When do you really enjoy smoking?
When do you think it will be the hardest for you to give up?
Why do you want to stop smoking?
What will you do with the money you save?
Do you suffer from any allergies
Are you taking any mind altering medication?
Please tell me in your own words and as much detail as possible about your smoking habit.
Including anything you may think is relevant no matter how silly it may sound
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