Tobacco Cessation Self Screening e

Tobacco Cessation Self-Screening Patient Intake Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age
Upload a picture of the front of your primary medical insurance card *

Cancel of
Upload a picture of the back of your primary medical insurance card *

Cancel of
What is your relation to the cardholder?

Cardholder Spouse Dependent
If you are not the cardholder, enter the cardholder's name

First Name Last Name
If you are not the cardholder, enter the cardholder's date of birth

Month Day Year
Date
If you are not the cardholder, what is the cardholder's gender?
PCP/Health Care Provider's Name
List of medicine you take *
Any allergies to medicines? *

Yes No
If yes, list them here
Any food allergies (ex. menthol/soy) *
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 or slowly reducing the number of cigarettes you smoke a day Medicine
Medicine

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
Are you under 18 years old?
Are you pregnant, nursing or planning on getting pregnant or nursing in the next 6 months?
Are you currently using and trying to quit non-cigarette products (ex. Chewing tobacco, vaping, e-cigarettes, Juul)?

Medical History *

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

Do you smoke fewer than 10 cigarettes a day? *

Yes No
STOP

Stop here if patient and pharmacist are considering nicotine replacement therapy.
KEEP GOING

If patient and pharmacist are considering non-nicotine replacement therapy (ex. varenicline or bupropion) continue to answer the questions below.

Medical History Continued:

	Yes	No	Not sure
Have you ever had an eating disorder such as anorexia or bulimia?
Have you ever had a seizure, convulsion, significant head trauma, brain surgery, history of stroke, or a diagnosis of epilepsy?
Have you ever been diagnosed with chronic kidney disease?
Have you ever been diagnosed with liver disease?
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
Do you take a monoamine oxidase inhibitor (MAOI) antidepressant? (ex. selegiline [Emsam®, Zelapar®], Phenelzine [Nardil®], Isocarboxazid [Marplan®],Tranylcypromine [Parnate®], Rasagiline [Azilect®])
Do you take linezolid (Zyvox®)?
Do you use alcohol or have you recently stopped taking sedatives? (ex. Benzodiazepines)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Not At All	Several Days	More Than Half the Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed or hopeless

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?

Not At All Several Days More Than Half the Days Nearly Every Day
Patient Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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