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Tell Us About Yourself

Medical Conditions

Medical screening questions are asked to determine if there are any potential contraindications for any or all types of quit medication recommendations.

All fields required All questions are required At least one selection is required
When you enroll in the Colorado QuitLine, you will have access to free personalized phone coaching, free patches or gum, an interactive website and text messaging support.










Yes
Do you have a history of any of the following? Check all that apply.
Yes
Yes
Has a healthcare provider told you not to use Nicotine Replacement Therapy, such as the patch, nicotine gum, or lozenge?

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