Male ____        Female ___                            Age _________                Grade Level ________
 

1.    Do you currently use tobacco products?  Yes    No

2.    If yes, which one(s)       cigarettes    cigars    smokeless tobacco

       If no, have you ever used tobacco products?    Yes    No

3.   How long have you used a tobacco product?   (years) 1-3       4-6      7-9     10+

4.   How much of this product do you use in a day?  _________________

5.   Do your parents smoke?   Yes     No