Tobacco Litigation Referral Service Questionnaire

Name:

Address:

City:    State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY     Zip code:

Daytime Telephone:    Evening Telephone:

Best time to call:

On behalf of:

Illness:

Date Diagnosed:

Current Age:

Age he/she started smoking:

Brand(s):

Number of Packs/day:

Currently Smoking: Yes No

Attempted to Quit?: Yes No

Quit Date: