Tobacco Cessation Program Enrollment

Tobacco Cessation Program Enrollment — Form Fields

This healthcare template includes 11 fields. Patients enroll in a structured tobacco cessation program with readiness assessment and preferences. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Tobacco Type Used (dropdown selection, required) — options: Cigarettes, Cigars, Pipe, Chewing Tobacco, E-Cigarettes/Vaping, Multiple
• Cigarettes or uses per day (number, required)
• Years of tobacco use (number, required)
• Previous Quit Attempts (dropdown selection, required) — options: None, 1–2 Attempts, 3–5 Attempts, More than 5 Attempts
• Interested in Nicotine Replacement Therapy? (dropdown selection, required) — options: Yes, No, Want to Discuss
• Interested in Medication (Chantix/Wellbutrin)? (dropdown selection, required) — options: Yes, No, Want to Discuss
• Preferred Support Format (dropdown selection, required) — options: Individual Counseling, Group Program, Phone Coaching, App-Based, Combination