Smoking Cessation Client Assessment

Smoking Cessation Client Assessment

Prescribing Consultation: $25 Per Session (except for Medi-Cal patients as it is a covered service).Your pharmacist will review the information provided in advance of your appointment.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Apt or Unit #

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
(1) Current tobacco use:
Number of cigarettes per day? *
First cigarette within 30 minutes of waking? Yes No*
(2) Previous quit attempts?: Yes No*
(3) Are you pregnant or plan to become pregnant?
Yes No N/A*
(4) Have you had a heart attach in the last two weeks?
Yes No*
(5) Do you have a history of heart palpitations, irregular heartbeats, or have you been diagnosed with a serious arrhythmia?
Yes No*
(6) Do you currently experience frequent chest pain or have you been diagnosed with unstable angina?
Yes No*
(7) Do you have any history of allergic rhinitis (nasal allergies)?
Yes No*
(8)Have you been diagnosed with temporal mandibular joint dysfunction (TMJ)?
Yes No*
Signature*

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