Smoking Cessation Risk Assessment Form
About You
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Male
Female
NHS Number (if known)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Name of your General Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
About your health
Do you have any recent or past medical history of note?
*
Yes
No
If Yes, may you please explain
Have you had a serious reaction to a varenicline before?
*
Yes
No
If Yes, may you please explain
Have you received advice from a smoking cessation counsellor before?
*
Yes
No
Have you tried to quit using nicotine replacement therapy (NRT) before?
*
Yes
No
If Yes, may you please explain
Are you on any medicines? Such as antiepileptics, antidepressants, antipsychotics, B-blockers, type 1C antiarrhythmics, cimetidine, theophylline or warfarin?
*
Yes
No
If Yes, may you please explain
Do you have a medical history of any of the following: renal / kidney problems, psychiatric illnesses (with symptoms of irritability or depression), myocardial infarction (MI) or risk factors for MI?
*
Yes
No
If Yes, may you please explain
Women only
Are you pregnant or planning a pregnancy?
Yes
No
Are you breastfeeding?
Yes
No
Acknowledgements
Do you understand that you must seek prompt medical advice if you develop agitation, depressed mood, or suicidal thoughts whilst taking varenicline?
*
Yes
No
Do you feel sufficiently motivated to quit smoking (willing to set a quit date between days 8 and 14 of starting treatment)?
*
Yes
No
Do you agree to receive weekly face-to-face motivational support for the first four weeks at least?
*
Yes
No
Submit
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