Qualtrics Survey | Qualtrics Experience Management

Please provide your first and last name below

Please provide your phone number to further discuss your eligibility in the study.

What is your age?

Which sex do you identify with?

Male
Female
Non-binary / Other

Please provide your estimated height below (in ft or cm)

Please provide your estimated weight below in pounds

Are you a smoker or non-smoker?

Smoker
Non-Smoker

Which study group applies to you?

Cigarette Group (I am a cigarette smoker)
Hookah Group (I am a hookah smoker)
Non-Smoker Group (I am a non-smoker)

Based on the study group you provided above, how old were you when you started smoking (please provide exact age of first usage)?

Cigarette Group - Years Old
Hookah Group - Years Old
Non-Smoker/Not Applicable

Based on your smoking group, how often do you smoke? Please provide the number of times you smoke in days, per week or per month.

Cigarettes - Days per week
Cigarettes - Days per month
Hookah - Days per week
Hookah - Days per month

Do you use prescription medications and/or vitamins?

Yes
No

If you identify as a female, do you currently use any type of contraception?

Yes, please specify which type below
No
I do not identify as a female

Do you have any chronic medical conditions such as (but not limited to): asthma, hypertension, diabetes, anemia, cancer, coronary artery disease, stroke, psychiatric illness, neurological disease, and liver or kidney disease?

Yes
No