Microsoft word - tobacco use cessation counseling form.doc

TOBACCO USE CESSATION COUNSELING
INITIAL ASSESSMENT
PATIENT: ________________________________________ DATE: _____/_____/_________
(Last Name) (First Name)
Do you currently smoke or use any type of tobacco product? ❏ YES ❏ NO
Have you ever smoked or used any type of tobacco product in the past? ❏ YES ❏ NO
IF YOU ANSWERED “NO” TO THE ABOVE QUESTIONS, YOU DO NOT NEED TO
CONTINUE COMPLETION OF THIS FORM. IF YOU ANSWERED “YES” TO THE
EITHER QUESTION, PLEASE CONTINUE.
What forms of tobacco do (did) you use? (Cigarettes, cigars, pipe, chewing tobacco, loose
leaf tobacco, other) – please list below:
___________________________________________________________________________
____________________________________________________________________________
On a daily basis, how often or how much tobacco do (did) you use? ___________________
Are you interested in receiving counseling and treatment options from your physician for
tobacco use cessation (quitting)? ❏ YES ❏ NO

IF YES, THEN PLEASE ANSWER THE REMAINING QUESTIONS.

Have you tried to quit using tobacco in the past? ______________________________
What methods of quitting have you tried? ____________________________________
________________________________________________________________________
Why do you feel you have been unable to quit? ________________________________
________________________________________________________________________

__________________PATIENT STOP HERE__________________

Physician’s suggestions:
❏ Nicotine Replacement Therapy
❏ Zyban/Wellbutrin
❏ Chantix
❏ Behavior Modification
❏ Situational Avoidance
❏ Oral Substitution
❏ Other _____________________________________________________________________
Return for follow up: _________________________________________________________
Physician Signature: ____________________________ DATE: ______/______/__________
NOTE: Please print and bring to your appointment. PCCS-Tobacco Use Initial (02/2013)
TOBACCO USE CESSATION COUNSELING
FOLLOW UP ASSESSMENT

PATIENT: ________________________________________ DATE: _____/_____/_________
(Last Name) (First Name)

Are you still continuing to smoke or use any type of tobacco product? ❏ YES ❏ NO

IF YOU ANSWERED “NO” TO THE ABOVE QUESTION, YOU DO NOT NEED TO
CONTINUE COMPLETION OF THIS FORM. IF YOU ANSWERED “YES” TO THE
ABOVE QUESTION, PLEASE CONTINUE THIS FORM.
Do you feel you have been able to decrease your tobacco use? ________________________
On a daily basis, how often or how much tobacco do you use? ________________________
Which method(s) have been the most helpful in decreasing your tobacco use? ___________
_____________________________________________________________________________
What do you feel is still your biggest deterrent for quitting? __________________________
______________________________________________________________________________
__________________PATIENT STOP HERE__________________
Physician’s suggestions:
❏ Nicotine Replacement Therapy
❏ Zyban/Wellbutrin
❏ Chantix
❏ Behavior Modification
❏ Situational Avoidance
❏ Oral Substitution
❏ Other _____________________________________________________________________
_____________________________________________________________________________
Return for follow up: __________________________________________________________
Physician Signature: ____________________________ DATE: ______/______/__________
NOTE: Please print and bring to your appointment. PCCS-Tobacco Use Initial (02/2013)

Source: http://www.pccsnova.com/forms/nvpccs_Tobacco_Counseling_Form.pdf