Email address:
Password :
Re-type password :
(6-12 characters, a-z, 0-9)
Personal Particular
Name :
(6-25 characters, a-z
)
Gender :
M
F
Age :
Below 18
19 - 40
41 - 65
Above 65
Smoking History
Q1.
How long have you smoked (Please specify) ?
1
2
3
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5
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98
99
year(s)
Q2.
How many cigarette do you smoke every day ?
10 or less
11 - 20
21 - 30
31 or more
Q3.
Have you tried to quit smoking ?
Yes, How many times ?
once
2 - 5 times
6 - 10 times
more than 10 times
No
Medical History
Cardiovascular diseases
Cerebrovascular diseases
Renal diseases
Neurological diseases
Pregnancy / Lactation
Others (please specify) : (Max: 50 characters)
Do you want to quit smoking?
All personal information collected are for registration purposes only and will be kept strictly confidential. For detail, please see Interactive Online Cessation Centre's
Privacy Policy
.
Type the code shown:
Smoking Cessation Hotline, Department of Health : 1833183
