appendix b - smoking assessment with script

7/30/2019 Appendix B - Smoking Assessment With Script

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SMOKING ASSESSMENT:

NAME: ________________________________ AGE: ______________ Date: _____________

SEX: M/F ETHNICITY: __________________ ZIP: _______________

1. Do you smoke or have you ever smoked cigarettes? Yes No I quit smoking2. Why did you start smoking? _________________________________________________________3. How many packs/cigarettes in a day? ___________________________4. For how many years? ___________________________5. Do you smoke menthol cigarettes? Yes No6. Have you ever tried to quit smoking? Yes No

If more than once how many times? ____________________

7. Why did you quit? __________________________________________________________________8. Did you use: Cold Turkey Medication Nicotine patch Nicotine Gum

Counseling Hypnosis Other: ___________________________________________

9. For how long did you quit? ____________________________________________________________10.Why did you start smoking again? ______________________________________________________11.Does anyone in your house smoke? Yes No

If yes, whom?_________________________________________________________________________

12.Why do you smoke? _______________________________________________________________________________________________________________________________________________________

13.What reason would it take for you to quit smoking? _____________________________________________________________________________________________________________________________

In the last month, how often have you felt that youwere unable to control the important things in yourlife?

In the last month, how often have you felt confidentabout your ability to handle your personal problems?

In the last month, how often have you felt that thingswere going your way?

In the last month, how often have you felt difficultieswere piling up so high that you could not overcomethem?

Almost FairlyVery

Never Never Sometimes Often

Often0 1 2 3

OFFICIAL USE ONLY

____ Ask Weekly phone calls explained: Y/N

____ Advise One Month follow up explained: Y/N____Assess

____Assist Additional Comments:_________________________________

____Arrange ____________________________________________________

Stress score: ______


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Weekly phone call script:

1. Have you quit smoking since your last visit to the clinic?a. If patient says NO, ask:

i. Why?ii.

Offer tapering off as alternativeiii. Have they utilized any resources?

iv. Is there anything else that can be done to help them quitb. If YES, continue:

2. Have you slipped up or relapsed?a. If YES:

i. How many times?ii. Determine reason for slip up

iii. Counsel patient based on 5Asb. If No, continue

3. How are your cravings?a.

Positive reinforcementb. Reiterate craving specific resources from NYC Smokefree.com

4. Close with:WHMC Family medicine program is committed to helping you achieve a healthy

lifestyle and a big part of that is quitting cigarettes and living a smoke free lifestyle. We

are here for you; please call us if you have any questions or concerns.

LAMARCA: 718.647.1700

MASTORNADI: 718.963.6730

ONE-MONTH FOLLOW UPDATE:______________________

Online Survey completed: ____Yes ____No

Additional

Comments:______________________________________________________________________

Physician Name (Print) _________________________________

Date __________________________

Physician Signature____________________________________


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WEEKLY PHONE CALL DOCUMENTATION SHEET:

Please fill out each section after each interaction with the Patient, do NOTmake any references to these formsin the patient chart.

WEEK 1DATE:_________________

Smoking Status: ____Quit ____Tapering down ____No change

____Relapsed (# of relapses/reason):____________________________________________________________

Complaints:________________________________________________________________________________

Additional Comments:_______________________________________________________________________

WEEK 2DATE:_________________



Complaints:________________________________________________________________________________

Additional Comments:______________________________________________________________________

WEEK 3

DATE:_________________



Complaints:________________________________________________________________________________


WEEK 4DATE:_________________



Complaints:________________________________________________________________________________


appendix b - smoking assessment with script

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