Patient Example: Amy's Tobacco Assessment Form

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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

 

2. Do you currently smoke cigarettes or use any other tobacco product?
  __X__ Yes
 

_____ No -- Date Stopped

If you answered yes to questions 1 or 2, please answer the following:

Type of tobacco and brand name: cigarettes

Length of use (in months or years): 1 year

Amount used per day on average: 4-6 cigarettes

3. Does anyone you live with or who is close to you smoke cigarettes or use other forms of tobacco?
  ______ Yes
  __X___ No

(Continue only if you answered yes to question 2)

4. How soon after you wake up do you smoke your first cigarette or use other forms of tobacco?
  __X__ Within 30 minutes
 

_____ More than 30 minutes

 

5. How interested are you in stopping smoking or stopping use of other forms of tobacco?
  __X___ Not at all
  ______ A little
  ______ Some
 

______ Very

 

6. If you decided to quit smoking or using other forms of tobacco completely during the next 2 weeks, how confident are you that you would succeed?
  _____ Not at all
  __X____ A little
  _______ Some
 

_____ Very

 

7. Have you ever intentionally quit smoking or using other forms of tobacco for 24 hours or longer?
  ____ Yes ___X__ No
  In the past year? _____ Yes ____ No
  In the past month? _____ Yes ____ No
  Since your last visit? _____ Yes ____ No

(Adapted from Heatherton et al., 1991)

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