Appendix B - Smoking Assessment With Script

1
SMOKING ASSESSMENT:
NAME: ________________________________ AGE: ______________
Date: _____________
SEX: M/F
ETHNICITY: __________________
ZIP: _______________
1.
2.
3.
4.
5.
6.
Do you smoke or have you ever smoked cigarettes?

Yes
No
I quit smoking
Why did you start smoking? _________________________________________________________
How many packs/cigarettes in a day? ___________________________
For how many years? ___________________________
Do you smoke menthol cigarettes?
Yes
No
Have you ever tried to quit smoking?
Yes
No
If more than once how many times? ____________________
7. Why did you quit? __________________________________________________________________
8. Did you use:
Cold Turkey
Medication
Nicotine patch
Nicotine Gum
Counseling
Hypnosis
Other: ___________________________________________
9. For how long did you quit? ____________________________________________________________
10. Why did you start smoking again? ______________________________________________________
11. Does anyone in your house smoke?
Yes
No
If yes, whom? _________________________________________________________________________
12. Why do you smoke? ___________________________________________________________________
____________________________________________________________________________________
13. What reason would it take for you to quit smoking? _________________________________________
____________________________________________________________________________________
Never
In the last month, how often have you felt that you
were unable to control the important things in your
life?
In the last month, how often have you felt confident

about your ability to handle your personal problems?
In the last month, how often have you felt that things
were going your way?
In the last month, how often have you felt difficulties

were piling up so high that you could not overcome
them?
Almost
Very
Never
Often
Fairly
Sometimes
Often
OFFICIAL USE ONLY
____ Ask
____ Advise
____Assess
____Assist
____Arrange
Stress score: ______
Weekly phone calls explained:

One Month follow up explained:
Y/N
Y/N
Additional Comments:_________________________________
____________________________________________________
Weekly phone call script:

1. Have you quit smoking since your last visit to the clinic?
a. If patient says NO, ask:
i. Why?
ii. Offer tapering off as alternative
iii. Have they utilized any resources?
iv. Is there anything else that can be done to help them quit
b. If YES, continue:
2. Have you slipped up or relapsed?
a. If YES:
i. How many times?
ii. Determine reason for slip up
iii. Counsel patient based on 5As
b. If No, continue
3. How are your cravings?
a. Positive reinforcement
b. Reiterate craving specific resources from NYC Smokefree.com
4. Close with:
WHMC Family medicine program is committed to helping you achieve a healthy
lifestyle and a big part of that is quitting cigarettes and living a smoke free lifestyle. We
are here for you; please call us if you have any questions or concerns.
LAMARCA: 718.647.1700
MASTORNADI: 718.963.6730
ONE-MONTH FOLLOW UP DATE:______________________

Online Survey completed:
____Yes
____No
Additional
Comments:______________________________________________________________________
Physician Name (Print) _________________________________

Date __________________________
Physician Signature____________________________________
3
WEEKLY PHONE CALL DOCUMENTATION SHEET:
Please fill out each section after each interaction with the Patient, do NOT make any references to these forms
in the patient chart.
WEEK 1 DATE:_________________
Smoking Status:
____Quit
____ Tapering down
____No change
____Relapsed (# of relapses/reason):____________________________________________________________
Complaints:________________________________________________________________________________
Additional Comments:_______________________________________________________________________
WEEK 2 DATE:_________________
Smoking Status:
____Quit
____ Tapering down
____No change
Complaints:________________________________________________________________________________
Additional Comments:______________________________________________________________________
WEEK 3 DATE:_________________
Smoking Status:
____Quit
____ Tapering down
____No change
Complaints:________________________________________________________________________________
WEEK 4 DATE:_________________
Smoking Status:
____Quit
____ Tapering down
____No change
Complaints:________________________________________________________________________________

Appendix B - Smoking Assessment With Script

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Appendix B - Smoking Assessment With Script

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1

Do you smoke or have you ever smoked cigarettes?

In the last month, how often have you felt confident

In the last month, how often have you felt difficulties

OFFICIAL USE ONLY

Weekly phone calls explained:

Weekly phone call script:

ONE-MONTH FOLLOW UP DATE:______________________

Physician Name (Print) _________________________________

____ Tapering down

____ Tapering down

____ Tapering down

____ Tapering down

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