Name:
Phone:	Cell:
Best Time to Call:
Street Address:
City:	State:
Zip Code:
Email:
Age:	<18 18-29 30-39 40-49 50-59 >59
Height:
Weight:
How long did you use Chantix® ? < 2 weeks 2-4 weeks >4-8 weeks > 8 weeks
When did you use Chantix® ? 2006 2007 2008 2009 2010
What is your injury? Diabetes Glucose Intolerance Seizure Skin Disorder Self-harm Thoughts of Self-harm Other
Date of Injury
Additional Comments:
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