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CLIENT/PATIENTASSESSMENT FORM
Nicotine Dependence Clinic
Client/Patient Name ___________________________ Health Record #_______________ I HISTORY OF SMOKING
1. At the present time do you smoke cigarettes? Daily Smoker:
2. How many cigarettes do you usually smoke each day? _______ (enter #of cigarettes)
3. How many cigarettes did you smoke each day during the period
WHEN YOU SMOKED THE MOST?
4. How old were you when you first started smoking daily? _______ (enter age)
Occasional Smoker:

5. If you are not a daily smoker (at least 1 cigarette in a 24-hr period), what has been your
pattern over the past 14 days? Please write the number of cigarettes for each day.
Mon_____ Tues_____ Wed_____ Thurs_____ Fri_____ Sat_____ Sun_____ Mon_____ Tues_____ Wed_____ Thurs_____ Fri_____ Sat_____ Sun_____ 6. How many cigarettes have you smoked in the past 30 days?_______ (enter # of cigarettes) 7. For how long have you been smoking this amount? 8. How old were you when you first started smoking?
II CESSATION HISTORY

9. Since you started smoking on a regular basis, what is the longest time you have gone
10. Describe the circumstances why you didn’t use any tobacco product (i.e. hospitalized, pregnant, decided to quit, N/A) _____________________________________________________________________________ 11. Have you ever tried to quit smoking? (If ‘yes’ please skip to question # 14) ο No ο Yes 12. What makes it difficult to quit smoking? ____________________________________________________________________ ____________________________________________________________________ 13. Which one of the following reasons comes closest to why you continue smoking? ο I have never smoked or I have smoked only a few times ο Other reason (please state reason) _________________ 14. What were the main reasons you stopped smoking? Please check all that apply. ο Restrictions on where you can smoke ο Cost/financial 15. In the past year, how many times have you quit smoking for at least 24 hours? 16. When was your last attempt to stop smoking? ο Within the past month ο 1-6 months ago 17. Which of the following approaches have you tried in your previous attempt(s) to stop smoking? Please check all that apply ο Self help materials, specify_________ 18. Which of the following symptoms, if any, have you experienced when you stopped smoking? 19. IF smoking again, what led you to it?
_________________________________________________________________________
_________________________________________________________________________
Nicotine Gum
20. Have you ever used nicotine gum to help you stop smoking?
a. If ‘no’ please skip to ‘Nicotine Patch’ section b. If ‘yes’, while using the gum, on average, how many pieces did you use per day? 23. Were you able to stop smoking when you used the nicotine gum? 24. Did you stop using nicotine gum because of side effects? If ‘yes’, indicate what the side effects were: Nicotine Patch
25. Have you ever used nicotine patches to help you stop smoking?
a. If ‘no’, skip to ‘Zyban’ section b. If ‘yes’, which of the following brands did you use? 26. What was the highest daily dose? (We are interested in knowing your highest dose of nicotine, if you used more than one patch simultaneously) 27. At most, how many patches did you wear at the same time? ___________ 28. How many weeks did you use nicotine patches? 29. Were you able to stop smoking while using nicotine patches? 30. Did you stop using nicotine patches because of the side effects? Zyban ® aka Wellbutrin ® or Buproprion ®

31. Have you ever used medications, such as, Zyban to help you stop smoking? ο No οYes
a. If ‘no’ please skip to question ‘Motivation/Social Support’ section b. If ‘yes’ please specify: ____________________________________ 34. Were you able to stop smoking while using Zyban? 35. Did you stop using Zyban because of the side effects? 36. Did you use any other treatments in combination with Zyban? If ‘yes’, indicate all that were used: ο Other treatment (i.e. acupuncture) ______________________________ III MOTIVATION/ SOCIAL SUPPORT:
37. Are you seriously planning to permanently stop smoking?
ο Yes, have already stopped ο Yes, at this appointment 38. On a scale from 1-10, (where 1=not important at all and 10=extremely important) how important is it for you to stop smoking? Please check only one. 39. On a scale from 1-10, (where 1=not confident at all and 10=extremely confident) how confident do you feel about your ability to stop smoking? Please check only one. 40. What is the most important reason why you want to cut down on the amount you 41. What are the obstacles you face in stopping or staying free from smoking? 42. Does anyone you live with regularly smoke or use tobacco? a. If ‘no’ please skip to question #44 b. If ‘yes’ please specify the following: i. Name (s): 43. Is he/she trying to quit smoking? ο No If ‘yes’ please indicate what methods he/she is using? 44. Are you ready to set a stop/quit date? ο No ο Yes ____________ (dd/ mm/ yyyy) Quit date (if already quit) ____________ (dd/ mm/ yyyy) STAGE OF CHANGE
TREATMENT PLAN
COMMENTS:

______________________________ ______________________________ Print Name (Therapist)
Signature & Credentials

Source: http://www.reseaufranco.com/en/assessment_and_treatment_information/assessment_tools/client-patient%20assessment%20form%20-%20nicotine%20dependence%20clinic.pdf

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