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

1. How many cigarettes a day do you smoke?
Check Mark Over 26 cigarettes a day (2)
About 16-25 cigarettes a day (1)
Check Mark About 1-15 cigarettes a day (0)
Check Mark Less than 1 a day (0)
2. Do you inhale?
Check Mark Always (2)
Quite often (1)
Seldom (1)
Never (0)
3. How soon after you wake do you smoke your first cigarette?
Within the first 30 minutes (1)
Check Mark More than 30 minutes after waking but before noon (0)
In the afternoon (0)
In the evening (0)
4. Which cigarette would you hate to give up?
Check Mark First cigarette in the morning (1)
First cigarette before noon (0)
Any other cigarette in the afternoon (0)
Any other cigarette in the evening (0)
5. Do you find it difficult to refrain from smoking in places where it is forbidden (church, library, movies, etc.)?
Check Mark Yes, very difficult (1)
Yes, somewhat difficult (1)
No, not usually difficult (0)
No, not at all difficult (0)
6. Do you smoke if you are so ill that you are in bed most of the day?
Yes, always (1)
Check Mark Yes, quite often (1)
No, not usually (0)
No, never (0)

7. Do you smoke more during the first 2 hours than during the rest of the day?

Yes (1) blank No (0)

Scoring:

Calculating the total points determines whether a patient is dependent on nicotine.

0-2 = no dependence

3-5 = moderate dependence

6+ = strong dependence

The higher the score, the more likely the patient is to experience withdrawal symptoms upon cessation and the more likely that symptoms will be severe.

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