NicOff Smoking Cessation Questionnaire
Thank you for choosing NicOff 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 with the Privacy Act 2014. Please read and complete this questionnaire carefully.
New or Repeat Assessment Declaration
Have you used NicOff before?
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No, this is my first time using NicOff service (or I am not sure/can't remember)
Yes, I am a repeat patient of NicOff
Legal Name on Medicare/Services Australia
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First Name
Middle Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Gender (on Medicare)
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Please Select
Male
Female
Other/Non Binary
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age and Intention Declaration
All medical guidelines strongly discourage the 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 trialed approved forms of Nicotine Replacement Therapies (NRTs). We strongly recommend behavioral support to accompany your smoking cessation journey.
I declare that I am currently/previously a tobacco or cigarette smoker
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Yes
No
I declare that I am using this service to reduce/quit/keep off smoking
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Yes
No
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SMOKING HISTORY
Smoking Status
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I currently smoke cigarettes but want to quit
I have completely quit smoking and only vape nicotine liquids
I still smoke, but have reduced smoking and currently vape nicotine liquids (please note we discourage 'dual usage,' and vapers should aim to completely quire cigarette smoking)
How many years have/did you smoke cigarettes for in total?
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1-5 years
6-10 years
11-20 years
>20 years
How many cigarettes do you currently smoke a day? If you are an ex-smoker, how many cigarettes did you used to smoke a day? Please select the most applicable option.
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Current smoker, 1-5 cigarettes
Current smoker, 6-10 cigarettes
Current smoker, 11-20 cigarettes
Current smoker, >20 cigarettes
Ex-smoker, 1-5 cigarettes
Ex-smoker, 6-10 cigarettes
Ex-smoker, 11-20 cigarettes
Ex-smoker, >20 cigarettes
How many times have you tried to quit smoking
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1-5 times
6-10 times
>10 times
What is/was the longest period you remained smoke-free?
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Less than a week
1-4 weeks
1-3 months
3-6 months
More than 6 months
More than 1 year
When was your last cigarette/tobacco use?
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Today
Within the past 1-4 weeks
Over 1-6 months ago
Over 6-12 months ago
Over 1-2 years ago
Over 2-5 years ago
Over 5 years ago
Have you spoken to your doctor/GP about advice regarding quitting smoking? (Please answer honestly, it does not affect the outcome)
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Yes, recently in the past 6 months
Yes, but more than 6 months ago
No I have not
Vaping is not a 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 trialled previously:
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Cold Turkey
Hypnosis/Phycologist counselling
Nicotine skin patches
Nicotine gum, quick mist, oral strips or lozenges
Doctor prescribed Varenicline (Champix)
Doctor prescribed Bupropion (Zyban)
Other
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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?
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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?
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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 breastfeeding. If you are or planning to be pregnant or breastfeeding, please contact clinic@nicoffclinic.com.au first
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I declare that I am not currently or planning to be pregnant/breastfeeding; or I am a male
I am pregnant/breastfeeding but have discussed this with my GP or NicOff
Please list any diagnosed medical conditions you have, including hypertension, heart disease, lung disease, mental health disorders
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Please write 'none' if you don't have any other diagnosed medical conditions
What regular medications do you currently take, if any?
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Please write 'none' if you are not taking other regular medications
Are you taking any of the following medications?
Clozapine
Olanzapine
Haloperidol
Chlorpromazine
FLuvoxamine
Imipramine
Amitriptyline
Nortriptyline
Duloxetine
Warfarin
Insulin
Propranolol
Metoprolol
Verapamil
Diltiazem
Flecainide
Theophylline
Benzodiazepines
Opioids
HRT
Oral Contraceptives
None of the above
If you currently vape/previously vaped nicotine, how long have/had you been doing so?
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I'm completely new to vaping
Tried a few times
Few weeks
Few months to a year
1-2 years
2-5 years
More than 5 years
In the past 6 months, what is your vaping habit closest to?
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I'm completely new to vaping
I only vape socially, e.g., when with friends or certain activities
I vape everyday, but sporadically when I get cravings
I vape everyday, but consistently throughout the day
Other
Has your nicotine intake changed over the past 6-12 months?
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No, I have been vaping the same strength and volume over the past 6-12 months
Yes, I have managed to DECREASE the strength or volume I vape over the past 6-12 months
Yes, I have had to INCREASE strength or volume over the past 6 months
Other
Have you spoken to your doctor/GP about getting a prescription for nicotine vaping products? (Please answer honestly; it does not affect the outcome)
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Yes
No
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What type of DEVICE(S) do you use or planning to use?
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Refillable mods and tanks
Refillable Pods and device
Prefilled Pods and device
I'm new and I don't know
If you already have a vaping device(s) you're using or want to continue using, what brand/model is it?
Leave blank if you don't have one
Which PRODUCT TYPE/s are you looking to use?
Prefilled pods with or without a rechargeable battery device
Bottled Freebase Nicotine Premix Liquids for Refillable Devices
Bottled Salt Nicotine Premix Liquids for Refillable Devices
Nicotine-Free Prefilled Pods and/or Bottled Premix Liquids
Nicotine Pouches (Snus) - Tobacco Free
I don't know - please contact me to discuss
Which product/brand are you looking to use moving forward?
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If you're not sure, write 'not sure' and we will discuss appropriate products
Have you used the above product/type before?
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Yes, same brand and product
No, different brand but similar product type/strength
No, I have not used the above product or type before
Other
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PREFERRED CONTACT
If there are further questions, what is your preferred method of contact?
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Mobile
Email
Please write any questions or further comments here:
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 offence 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 NicOff contacting me by telephone, email, or SMS. AMENDMENTS: I understand that amendments within 4 weeks of the prescription being sent will incur a $20 amendment fee. I understand that NicOff is not responsible for any product strength/formulation changes that require new prescriptions. PAYMENT: I consent to making the payment in full and have the cardholder's authority to make it. REFUND POLICY: Full refunds are only permitted if a cancellation request is sent prior to doctor review and contact. No refunds are given once the assessment has been reviewed by the doctor or if the service has been completed and the prescription has been sent. DISCLAIMER: NicOff 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
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Yes
Signature
Purchasing Nicotine Vaping Products for someone else using my prescription is illegal and an offence. 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.
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Yes
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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)
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I am aiming to quit nicotine vaping within the next 3 months
I am aiming to quit nicotine vaping within the next 6 months
I am aiming to quit nicotine vaping within the next 12 months
I am aiming to quit nicotine vaping at some stage, but not sure when
I will likely vape indefinitely and do not think that I will quit vaping
Research shows the 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
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Not right now, maybe next time
Yes I definitely want to be contacted by Quitline
No I do not want to be contacted by Quitline at all
How did you hear about NicOff? (Select any that apply)
Facebook or other social media
Other vape websites or suppliers
Reddit
Pharmacy
GP or Other Healthcare Professional
Word of Mouth (family/friends/colleagues)
Google
Other
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Medicare or Individual Healthcare Identifier Number
This is for identity verification and electronic prescription purposes
Do you have a medicare card?
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Yes
No
Medicare Card Number
Medicare Card Expiry Date
Medicare Card IRN (Individual Reference Number)
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PAYMENT FOR DOCTOR ASSESSMENT
My Products
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Doctor Assessment Fee
Fee includes e-script(s) for up to 6 months
$
29.00
AUD
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