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I support smoke free casino floors and call on state and local policymakers to protect all people from the dangers of secondhand smoke now.

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Health Survey:
First name:
Last name:
Birth Year:
Are you currently employed in a casino?: Yes: No:
Total number of years worked in casino:
Job title:  
Job Other
Years at current job:
Do you currently smoke cigarettes?: Yes: No:
If yes, number of years:
Have you ever used tobacco?: Yes: No:
Check the boxes if you have been diagnosed with and or treated for the following health conditions:

(Check all that apply.)

Abdominal Aortic Aneurysm
Allergies
Asthma
Atherosclerosis
Breast Cancer
Cataracts
Other Eye Disease
Chronic Bronchitis
Coronary Heart Disease
COPD
Cervical Cancer
Fertility/Pregnancy Issues
 Hypertension
 Kidney Cancer
Leukemia
Lymphoma
Lung Cancer
Miscarriage
Mouth/Oral Cancer
Pancreatic Cancer
Periodontitis
Pneumonia
Sinus Problems
Skin Cancer
Stomach Cancer
Stroke
Throat/Larynx/Esophagus Cancer
Other Cancer:
Other Heart Disease:
Other Lung Disease :
Other Disease :

Comments:
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