var mybackend_page = '
Your Name:
Address:
Telephone Number:
Email Address:
Age and Date of Birth:
Are you under the Age of 18?
Yes
No
If under the age of 18, the name of your guardian/parent:
Are you married?
Yes
No
If married, the name of your spouse:
When did you begin to use smokeless tobacco products?
Describe how and why you started to use smokeless tobacco:
List the brands of smokeless tobacco products that you have used and the dates of use:
If you have tried to quit, list the dates and the longest period that you have quit:
If you have tried to quit, list any medications or treatments you have taken to quit:
Have you at any time smoked cigarettes, cigars, or pipe tobacco?
No
Yes
If you have smoked, identify all the dates that you have smoked and what type of products used:
Do you believe that you are or once were addicted to smokeless tobacco?
Yes
No
Have you been diagnosed or suffered from any of the following? (check all that apply)
Tooth loss
Tooth discoloration
Other
Cancer of the neck
Cancer of the throat
Cancer of the tongue
Cancer of the lip
Cancer of the cheek
Cancer of the gums
Cancer of the larynx
Cancer of the esophagus
Cancer of the stomach
Leukoplakia
Pre-cancerous lesions
Mouth, tongue, gum sores
Gum recession
For any condition above, describe in detail:
List any other significant medical condition that you have, whether related or unrelated to the use of smokeless tobacco:
Please list your eductational background, schools attended and degrees received:
Please list your employment information, employer name, job title, and job duties:
If you missed any time from work as a result of any medical condition related to smokeless tobacco, please describe the details:
If you have been a party to a lawsuit, please provide the details of your involvement, the type of case, and outcome:
If you have been convicted of any crime, please provide the date of the conviction and the charges that were brought:
May we contact you to discuss your case in greater detail?
Yes
No
'; document.write(mybackend_page);