assessment

Patient Example: Jason's Tobacco Use Assessment Form

Description: 
This is an example of a patient's responses to the Tobacco Use Assessment Form.

Tobacco Use Assessment for Jason

1. Have you ever smoked cigarettes or used any other tobacco product?
  __X__ Yes
 

_____ No

 

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Patient Example: Amy's Tobacco Assessment Form

Description: 
This is an example of a patient's responses to the Tobacco Use Assessment Form.

Tobacco Use Assessment for Amy Clark

1. Have you ever smoked cigarettes or used any other tobacco product?
  __X__ Yes
 

_____ No

 

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Patient Example: Jennifer's Youth Tobacco Assessment Form

Description: 
This is an example of a patient's responses to the Tobacco Use Assessment Form for Children or Teens.

Name: Jennifer Simpson

Date: 6/ 1 /2005

Have you ever smoked cigarettes or used any other tobacco product?
 
X   No
___ Yes, but just a little experimentation, for example, a few puffs of a cigarette
___ Yes, more than just experimenting. If Yes, please answer the following questions (A-C):

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Description: 
Fagerström Tolerance Questionnare for Adolescents
Source: 
Br J Addict and Addictive Behaviors
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Description: 
Tobacco Use Assessment Form for Children or Teens reproduced with modifications from: Choi, WS, Pierce, JP, Gilpin, EA, Berry, CC. Which adolescent experimenters progress to established smoking in the United States? Am J Prev Med. 1997; 13(5), 385-391.
Source: 
Choi, WS, Pierce, JP, Gilpin, EA, Berry, CC
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Patient Example: Tamika's Tobacco Assessment Form

Description: 
Patient Example: Tamika's Tobacco Assessment Form

Tobacco Use Assessment Form for Children or Teens

Name: Tamika Jones

Date: 6/ 1 /2005

Have you ever smoked cigarettes or used any other tobacco product?
_X_ No
___ Yes, but just a little experimentation, for example, a few puffs of a cigarette
___ Yes, more than just experimenting. If Yes, please answer the following questions:

Have you smoked at least 100 cigarettes in your life?
_X__ No
___ Yes

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Tobacco Use Stickers

Description: 
Stickers that indicate on a patient chart whether the patient is a smoker or non-smoker.

Use these stickers to indicate if a patient is a smoker or not:



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Patient Example: Amy's Fagerström Tolerance Questionnaire Results

Description: 
Patient Example of the Fagerström Tolerance Questionnaire for Adolescents

This is a patient's response to the Fagerström Tolerance Questionnaire for Adolescents.

Name:
Amy Clark

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What is Alcoholism?

Description: 
NIAAA definitions of alcoholism

What Is Alcoholism?

According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), alcoholism includes the
following four symptoms:
1. Craving -- A strong need, or urge, to drink.
2. Loss of control -- Not being able to stop drinking once drinking has begun.
3. Physical dependence -- Withdrawal symptoms, such as nausea, sweating, shakiness, and
anxiety, after stopping drinking.
4. Tolerance -- The need to drink greater amounts of alcohol to get "high."

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Vital Signs Chart

Description: 
Vital signs chart. Includes blood pressure, pulse, weight, temperature, respiratory rate, and tobacco use.

Use the following chart to record vital signs.

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