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):

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

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

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

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

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