| Name (First Last) |
|
| Street Address |
|
| Apt. |
|
| City |
|
| State/Province |
|
| Zip/Postal Code |
|
| Country |
|
| Email Address |
|
| Serial Number (located
on back of watch) |
|
| Your Age |
Under 25
25 - 34
35 - 44
45 - 60
Over 60 |
| Your Sex: |
Male
Female |
| Your Marital Status |
Single
Married
Divorced/Widowed |
| Number of Children |
0
1
2 - 3
4 or
more |
| Would you like to receive our
Quitting Time e-Newsletter? |
Yes
No |
| Would you like to receive product
updates via e-mail? |
Yes
No |
| Which version/color QT-Watch did you
purchase? |
Wristwatch
Keyclip,
black
Keyclip,
blue
Keyclip, other color.
Please specify:
|
| Did you purchase the QT-Watch: |
for you?
as a gift?
If so, for who?
(example: husband, uncle, father, friend,
etc.) |
| What was the key deciding factor in
purchasing a QT-Watch? (select only one, please) |
Doctor's advice
Other's advice
Style
Ability to monitor progress/track cigarettes
Sports watch functions
Motivational messages
Quitting Score™
Compatibility with medications and patches
Other,
please specify:
_ |
| How many times have you/your loved
one tried to quit smoking: |
First attempt
Once before
2-3 times
4-5 times
Over 7 times
Do not know |
| What other quitting products have
you/your loved one used? (Check all that apply) |
Patch
Oral Medication
Gum
Counseling/Support
Hypnosis
Other(s), please specify:
|
| Comments |
|
| May we contact you for a testimonial
or to clarify any of your above comments? |
Yes
No |
