Tobacco Cessation Self-Screening Patient Intake Form

Tobacco Cessation Self-Screening Patient Intake Form

CONFIDENTIAL- Protected Health Information
Date

MonthDayYear
Date
Date of Birth*

MonthDayYear
Legal Name*

First NameLast Name
Preferred Name

First NameLast Name
Sex Assigned at Birth*

MaleFemale
Gender Identification

MaleFemaleOther
Preferred Pronouns

She/Her/HersHe/Him/HisThey/Them/TheirZe/Hir/HirsOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Primary Care Provider
Primary Care Provider Phone Number
Please enter a valid phone number.
Primary Care Provider Fax
Please enter a valid phone number.
Do you have Health Insurance*

YesNo
Insurance Provider Name
Front of Insurance Card
Back of Insurance Card
Any allergies to medications*

YesNo
Please list
Any allergies to foods (ex. menthol/soy)?*

YesNo
Please list
List of medication(s) you take
Do you consent to the pharmacy notifying your primary care provider should medication be initiated?*

YesNo
Do you have a preferred tobacco cessation product you would like to use?
Have you tried quitting smoking in the past? If so, please describe
What best describes how you have tried to stop smoking in the past?

"Cold turkey"Tapering of slowly reducing the number of cigarettes you smoke a dayMedicine - Nicotine replacement (like patches, gum, inhalers, lozenges, etc.), Prescription medications (ex. bupropion [Zyban®, Wellbutrin®], varenicline [Chantix®])Other

Health and History Screen - Background Information:*

	Yes	No	Not sure
1. Are you under 18 years old?
2. Are you pregnant, nursing, or planning on getting pregnant or nursing in the next 6 months?
3. Are you currently using and trying to quit non-cigarette products (ex. Chewing tobacco, vaping, e-cigarettes, Juul)?

Medical History:*

	Yes	No	Not sure
4. Have you ever had a heart attack, irregular heartbeat or angina, or chest pains in the past two weeks?
5. Do you have stomach ulcers?
6. Do you wear dentures or have TMJ (temporomandibular joint disease)?
7. Do you have a chronic nasal disorder (ex. nasal polyps, sinusitis, rhinitis)?
8. Do you have asthma or another chronic lung disorder (ex. COPD, emphysema, chronic bronchitis)?

Tobacco History:*

	Yes	No
9. Do you smoke between 0-4 cigarettes per day OR less than 1 can or pouch per week of snuff or chew?
10. Do you smoke between 5-10 cigarettes per day OR 1-2 cans or pouches per week of snuff or chew OR 3-6mg/ml e-liquid?
11. Do you smoke 11+ cigarettes per day OR 2 cans or pouches per week of snuff or chew OR 6-12+mg/ml e-liquid?

Blood Pressure blanks / blankmmHg
(Note: Must be taken by a pharmacist)

Stop here if patient and pharmacist are considering nicotine replacement therapy or blood pressure is > 160/100 mmHg.

If patient and pharmacist are considering non-nicotine replacement therapy (ex. varenicline or bupropion) and blood pressure is < 160/l00mmHg continue to answer the questions below.

Medical History Continued:*

	Yes	No	Not sure
12. Have you ever had an eating disorder such as anorexia or bulimia?
13. Have you ever had a seizure, convulsion, significant head trauma, brain surgery, history of stroke, or a diagnosis of epilepsy?
14. Have you ever been diagnosed with chronic kidney disease?
15. Have you ever been diagnosed with liver disease?
16. Have you been diagnosed with or treated for a mental health illness in the past 2 years? (ex. depression, anxiety, bipolar disorder, schizophrenia)?

Medication History:*

	Yes	No	Not sure
17. Do you take a monoamine oxidase inhibitor (MAOI) antidepressant? (ex. selegiline [Emsam®, Zelapar®], Phenelzine [Nardil®], lsocarboxazid [Marplan®], Tranylcypromine [Parnate®], Rasagiline [Azilect®])
18. Do you take linezolid?
19. Do you use alcohol or have you recently stopped taking sedatives? (ex. Benzodiazepines)

The Patient Health Questionnaire 2 (PHQ 2):*

	Not At All	Several Days	More Than Half the Days	Nearly Every Day
Over the last 2 weeks, how often have you been bothered by any of the following problems?: Little interest or pleasure in doing things
Feeling down, depressed or hopeless

Suicide Screening:*

	Not At All	Several Days	More Than Half the Days	Nearly Every Day
Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or have you hurt yourself or had thoughts of hurting yourself in some way?