form

An example of a stop-smoking agreement form

Description: 
An example a stop-smoking agreement form.

QUIT FOR GOOD RX
I agree to stop smoking on:
Date: _____/_____/______.
I understand that stopping smoking is the single best thing I can do for my health, and my
health professional has strongly encouraged me to quit.
Patient's Signature:________________________________
Health Professional's Signature:_____________________________
Today's Date:_____/______/_____

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Description: 
The NIDA quick screen is an online screening tool for substance abuse filled out by the patient. Based on the patient's responses, it generates a substance involvement score that suggests the level of intervention needed. This is the short, online version of the longer screening tool, the NIDA Modified ASSIST.
Source: 
NIDA
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