Medical Assessment

Medical Questionnaire

Thank you for choosing QuitRX to help you with your smoking cessation journey! Please note that this form is HIPAA-compliant and all data is considered private and confidential, and is stored in accordance to The Privacy Act 2014. Please read and complete this questionnaire carefully. ©2021 QuitRX
READ THE IMPORTANT INFORMATION:

From 1 July 2024, flavours allowed are tobacco, mint, menthol, unflavoured.

QuitRX does not:
- prescribe single use disposables
- prescribe or encourage Big Tobacco owned products or heated tobacco products
- have any affiliations or financial interest in any company or products
- prescribe ingredients to mix (including concentrated nicotine or 100mg/mL)
If you have your own refillable device, please note that hardware/accessories may become difficult to access and we will advise switching to pharmacy available products.

Please make sure to read the Frequently Asked Questions page on the website before you proceed.

NICOTINE POUCHES - DO NOT COMPLETE THIS FORM. There is a separate nicotine pouches assessment for importation
New or Repeat Assessment Declaration

If you have used QuitRX before, many questions will change, but as product usage may change over time, we will need to ask this again
Have you used QuitRX service before?*

No, this is my first time using QuitRX service (or I am not sure/can't remember)Yes, I am a repeat patient of QuitRX.
Legal Name on Medicare/Services Australia*

First NameLast Name
Date of Birth*

DayMonthYear
Must be over 21 years of age
Gender (on Medicare)*
Email*

Confirmation EmailPlease enter your email address twice to ensure this is correct, or we can't send you your prescription
Contact/Mobile Number*
Residential Address

No mail will be posted or delivered to this address.
Street Address*
Suburb*
State/Territory*
Postcode*
Age and Intention Declaration

All medical guidelines strongly discourage use of nicotine for vaping in non-smokers. This service is intended for current/ex-smokers as a method of smoking cessation, and is not appropriate or suitable for non-smokers. We do not prescribe for the purposes of starting nicotine or vaping outside of previous tobacco use. Nicotine Vaping Products (NVPs) are not intended to be used as first line therapy for smoking cessation, and ideally you should have trialled approved forms of Nicotine Replacement Therapies (NRTs). We strongly recommend behavioural support to accompany your smoking cessation journey.
I declare that I am currently/previously a tobacco or cigarette smoker*

Yes
I declare that I am using this service to reduce/quit/keep off smoking*

Yes
SMOKING HISTORY
Smoking Status*

I currently smoke cigarettes but want to quitI have completely quit smoking and only vape nicotine liquidsI still smoke, but have reduced smoking and currently vape nicotine liquids (please note we discourage 'dual usage' and vapers should aim to completely quit cigarette smoking)
How many years have/did you smoke cigarettes for in total?*

1-5 years6-10 years11-20 years>20 years
How many cigarettes do you currently smoke a day? If you are an ex-smoker, how many cigarettes did you use to smoke a day? Please select the most applicable option.*

Current smoker, 1-5 cigarettesCurrent smoker, 6-10 cigarettesCurrent smoker, 11-20 cigarettesCurrent smoker, >20 cigarettesEx-smoker, 1-5 cigarettesEx-smoker, 6-10 cigarettesEx-smoker, 11-20 cigarettesEx-smoker, >20 cigarettes
How many times have you tried to quit smoking?*

1-5 times6-10 times>10 times
What is/was the longest period you remained smoke-free?*

Less than a week1-4 weeks1-3 months3-6 monthsMore than 6 monthsMore than 1 year
Have you spoken to your doctor/GP about advice regarding quitting smoking? (Please answer honestly, it does not affect the outcome)

Yes, recently in the past 6 monthsYes, but more than 6 months agoNo I have not
Vaping is not first line treatment for smoking cessation. It can be considered after first line treatments (including behavioural support and approved pharmacotherapies) have failed. Please tick smoking cessation methods you have trialed previously:*

Cold TurkeyHypnosis/Psychologist counsellingNicotine patches/gum/spray (e.g. Nicabate, Nicorette)Doctor prescribed Varenicline (Champix)Doctor prescribed Bupropion (Zyban)Other
How motivated are you with your plans to quit SMOKING?*

I have already quit smoking, and now only vaping nicotineVery motivatedSomewhat motivatedNot very motivatedNot motivated at allOther
OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION
In the last 3 months, have you had UNCONTROLLED hypertension, irregular heartbeats/arrhythmia, stroke, angina or heart attacks?*

No, I do not have this (or my condition is well controlled)Yes I have this and require frequent medications or hospitalisations.
In the last 3 months, have you had UNCONTROLLED lung disease including asthma, emphysema or COPD?*

No, I do not have this (or my condition is well controlled)Yes I have this and require frequent medications or hospitalisations.
Nicotine vaping may not be safe in pregnancy or breast feeding. If you are or planning to be pregnant or breastfeeding, please contact hello@quitrx.com.au first*

I declare that I am not currently or planning to be pregnant/breastfeeding; or I am a maleI am pregnant/breastfeeding but have discussed this with my GP or QuitRX
Please list any diagnosed medical conditions you have, including hypertension, heart disease, lung disease, mental health disorders*
Please write 'none' if you don't have any other diagnosed medical conditions
What regular medications do you currently take, if any?*
Please write 'none' if you are not taking other regular medications
VAPING HISTORY
If you currently vape/previously vaped nicotine, how long have/had you been doing so?*

I'm completely new to vapingTried a few timesFew weeksFew months to 1 year1-2 years2 - 5 yearsMore than 5 years
In the past 6 months, what is your vaping habit closest to?*

I am completely new to vapingI only vape socially e.g. when with friends or certain activitiesI vape everyday, but sporadically when I get cravingsI vape everyday, and consistently throughout the dayOther
How soon after waking up do you smoke/vape?*

Within 5 minutes6-30 minutes31-60 minutesAfter 60 minutes or longer
Do you feel the need to smoke or vape just before bed?*

YesNo
[Has your nicotine intake changed over the past 6-12 months?]*

No, I have been vaping the same strength and volume over the past 6-12 monthsYes, I have managed to DECREASE the strength or volume I vape over the past 6-12 monthsYes, I have had to INCREASE strength or volume over the past 6-12 monthsOther
[You reported needing to INCREASE strength or volume of nicotine you are using over the past 6-12 months. Please let us know why?]*
Have you spoken to your doctor/GP about getting a prescription for nicotine vaping products? (Please answer honestly, it does not affect the outcome)*

YesNo
[What happened when you spoke with your GP about nicotine vaping products?]*

They were not supportive of nicotine vaping products or prescribing themThey were supportive of nicotine vaping products, but did not know how to prescribeOther
[What is the reason that you have not spoken to your doctor/GP regarding nicotine vaping products? Please select any that apply]*

I do not have a regular GPI am embarrassed or worried to speak to my GP about thisIt is difficult for me to find time to see my GPI think I am able to manage smoking cessation on my ownMy GP has a long waitlist and it is difficult to get an appointmentOther
What type of device(s) do you use or planning to use?*

Refillable Mods and tanksRefillable Pods and deviceSealed/Prefilled Pods and deviceI'm new, and I don't know
If you already have a vaping device(s) you're using or wanting to continue using, what brand/model is it?
Leave blank if you don't have one
Would you like to be referred to our online pharmacy at Astrid Dispensary?

No, I prefer to get products from my local pharmacyYes, please also send the prescription to Astrid Dispensary (you will be contacted to organise product ordering & $15 express postage fee)Other
Which pharmacy are you planning to get your products from?*
If you're not sure, please indicate so, we will provide appropriate recommendations
Which vaping product type are you looking to use? One selection per script allowed. We do not prescribe products owned by Big Tobacco, or ingredients for mixing.

Prefilled/sealed pods +/- rechargeable compatible battery deviceBottled Freebase Nicotine Premix Liquids - For Refillable DeviceBottled Salt Nicotine Premix Liquids - For Refillable DeviceI don't know, please contact me to discuss
[You selected a type of Prefilled Pod which contains Nicotine Salts. What strength do you think you may need for the next 3-6 months?]*

0% Nicotine-FreeLight smoker - Low Strength 1-2% (13 - 29mg/mL)Moderate smoker - Medium Strength 3-4% (30 - 40mg/mL)Heavy smoker - High Strength 5% (50mg/mL)I'm new and not sure, please discuss with me
[What is your average usage per pod?]*

1 pod daily1 pod 1-2 days1 pod 3-5 days1 pod weeklyI'm new and not sure
[You selected Premixed juices/e-liquids for refillable tanks/pods. What strength do you think you may need for the next 3-6 months? One strength per script allowed.]*

0mg/mL Nicotine-Free3mg/mL freebase6mg/mL freebase9mg/mL freebase12mg/mL freebase18mg/mL freebase20mg/mL (2%) salts30mg/mL (3%) saltsI'm new or not sure, please contact me to discuss
[How many mLs do you use per day on average?] *
Please double check to make sure it's correct, or if you're new please state as such
Which product/brand/strength are you looking to use moving forward?*
If you're not sure, write 'not sure' and we will discuss appropriate products
Have you used the above product/type before?*

Yes, same brand and productNo, different brand but similar product type/strengthNo, I have not used the above product or type before.Other
PREFERRED CONTACT
If there are further questions, what is your preferred method of contact? (Phone contact is within 2-3 business days; Email contact within 1-2 business days)*

Telephone callEmail
Please write any questions or further comments here (if there was any issues with the form let me know too):
CONSENT AND DECLARATION

By submitting this form, I declare that all information is true and accurate. I have read the terms and conditions, and privacy policy on the website. I confirm that I am the legal owner of the medicare details provided and understand that providing false or inaccurate information may be a criminal offense or misusing someone else's identity constitutes identity fraud. I understand that all information is confidential, and may be used by third parties for authorised identity verification purposes only. I understand that nicotine is an addictive substance with potentially harmful effects to users or bystanders, and its short or long term effects are largely unknown. I am aware that there are currently no products registered or approved by Therapeutic Goods Australia. I accept that any risks of using any nicotine vaping products are my own and will keep any nicotine products out of reach of children and adolescents to prevent accidental poisoning. CONTACT: I consent to QuitRX contacting me by telephone, email or SMS. AMENDMENTS: I understand that amendments within 4 weeks of the prescription being sent will incur a $25 amendment fee. I understand that QuitRX is not responsible for any product strength/formulation changes that require new prescriptions. PAYMENT: I consent to making payment in full, and have the cardholder authority to make payment. REFUND POLICY: Full refunds are only permitted if a cancel request is sent prior to doctor review and contact. Partial refunds are permitted if no prescription is sent. No refunds are given once the service has been completed and prescription has been sent. DISCLAIMER: QuitRX is not affiliated with any nicotine vaping brands or companies and does not endorse specific brands or products.
I have read the above statements, and I consent to treatment and agree to the above declaration statement*

Yes
Signature*

Clear
Purchasing Nicotine Vaping Products for someone else using my prescription is illegal and an offense. I declare that I am obtaining a prescription for my own personal use, or if completing on behalf of someone else, the details reflect the patient and they have consented to this.*

Yes
FOLLOW UP QUESTIONS
Regarding vaping timeframe - In your honest opinion, which best applies to you? (This helps with research purposes and answers have no impact on the assessment outcome)*

I am aiming to quit nicotine vaping within the next 3 monthsI am aiming to quit nicotine vaping within the next 6 monthsI am aiming to quit nicotine vaping within the next 12 monthsI am aiming to quit nicotine vaping at some stage, but not sure whenI will likely vape indefinitely and do not think that I will quit vaping
*So we can understand better, please briefly tell us why you do not feel that you will quit vaping.*
Research shows best successes of smoking/vaping cessation that combines behavioural intervention (Quitline). Would you like us to make a referral to Quitline for you? Please only select yes if you are serious about engaging with Quitline*

Yes I definitely want to be contacted by QuitlineNot right now, maybe next timeNo I do not want to be contacted by Quitline at all
How did you hear about QuitRX? (Select any that apply)*

Word of Mouth (family/friends/colleagues)PharmacyGP or Other Healthcare ProfessionalGoogleRedditFacebook or other social mediaVapoureyesOther vape websites or suppliersOther
Medicare or Individual Healthcare Identifier Number

This is for identity verification and electronic prescription purposes
Do you have a medicare card?*

YesNo
[What is your 10-digit medicare number?]*
Please input with no spaces
[What is your reference number that is next to your name?]*
[What is your 16-digit Individual Healthcare Identifier (IHI) number?] If you do not know, please check the link - https://www.servicesaustralia.gov.au/how-to-get-individual-healthcare-identifier?context=22591 *
https://www.servicesaustralia.gov.au/how-to-get-individual-healthcare-identifier?context=22591
PAYMENT FOR DOCTOR ASSESSMENT

Assessment Fee*

Doctor Assessment FeeFee includes e-script for up to 6 months

$49AUD

Total

$0.00AUD

Credit Card

**NOTE: Please make sure you press the submit button once and wait. After a few seconds, if the form submission is successful, you will be taken to a 'thank you' page and receive an email confirmation. Any issues please refresh your browser or try a different browser (works best with Google Chrome), otherwise contact hello@quitrx.com.au
PLEASE NOTE:

Please contact me (Dr Shu) at hello@quitrx.com.au if there are any issues with submitting the form - I can't fix issues I don't know about!

There are sometimes issues with browsers not allowing the submission (stuck 'please wait'), if you have issues please refresh the page, clear browser cache, or try a different browser or device. Thanks for your patience!

©2023 QuitRX
Should be Empty:

Medical Questionnaire

New or Repeat Assessment Declaration

Residential Address

Age and Intention Declaration

SMOKING HISTORY

OTHER MEDICAL HISTORY AND RISK FACTORS DECLARATION

VAPING HISTORY

PREFERRED CONTACT

CONSENT AND DECLARATION

FOLLOW UP QUESTIONS

Medicare or Individual Healthcare Identifier Number

PAYMENT FOR DOCTOR ASSESSMENT

Credit Card