Patient Example: Tamika's Tobacco Assessment Form

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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

On how many of the past 30 days did you smoke?
________ (number)

Are you no longer smoking? Date you quit? ____________
_X_   No
___ Yes

Do you think you will try a cigarette or other tobacco product soon?
_X__ No
___ Yes

Do you have a close friend or brother or sister who smokes or uses other tobacco products?
___ No
_ X_  Yes

Would you smoke a cigarette if a friend offered one?
_X__ No
___Yes

Do you think you will be smoking or using other tobacco products one year from now?
_X_ No
___Yes

Does anyone you live with or anyone who you are around a lot smoke cigarettes or use other forms of tobacco?
___ No
_X_ Yes

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.

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