intakequestionnaireform_000

8/12/2019 IntakeQUESTIONNAIREFORM_000

1/7

PORCUPINE HEALTH UNIT

QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE

1

FOR CLINIC USE ONLY

Client Name__________________________ File#__________________

A. GENERAL INFORMATION:

Name:

Home Telephone: Work Telephone:

Can we leave a message at your home indicating we are from the Quit Smoking Clinic?Yes No

Address:

Email Address:

Date of Birth: Sex: Female Male

Marital Status:SingleMarried /common lawDivorced/ SeparatedWidowed

Household members: I am (check allthat apply):

FrancophonePregnant

Aboriginal17 or younger

Name /Relationship to you

Age Smoker:

Yes No

Yes No

Yes No

Work Status:

Working full-timeWorking part-timeSelf employedRetiredDisabledUnemployedHousewife or househusbandStudent

If employed,

Job title:

Employer / School:

Please select the highest level of education you have completed:

Grade School University degreeGraduate school High School

Doctoral College diploma

Name of your Physician/Nurse Practitioner:

Address: Telephone Number:

Is your doctor/nurse practitioner aware that you are trying to quit? Yes No


2/7



2

1. How did you first hear about the Porcupine Health Units Quit Smoking Program?

Doctor Smokers HelplineNewspaper Ad Pharmacist

TV Pamphlet / PosterWebsite Your WorkplaceHealth Unit Family / FriendOther (please specify

B. MEDICAL HISTORY:

2. Have you ever been told by a doctor that you had any of the following conditions?

C. SMOKING PATTERN (Fagerstrom)

3. How soon after you wake up do you smoke your first cigarette?

Within 5 minutes6-30 minutes31-60 minutes

After 60 minutes

No YesDontKnow Please list your medications

Heart attack or angina

High blood pressure

Arrhythmias

Diabetes

Leg ulcers

Poor circulation

Peptic ulcer disease

Jaw problems

Mouth or throat inflammation

Allergies or skin sensitivities

Hyperthyroidism

Liver or kidney disease

Depression

Anxiety

Bipolar

Schizophrenia

ADHD


3/7



3

4. Do you find it hard not to smoke in places where it is not allowed, like a church, at themovies, school, bar, restaurant or hospital?

No Yes

5. Which cigarette would you hate the most to give up?

The first one in the morningAny other one

6. Please check () how many cigarettes you smoke each day?

10 or less 11-20 21-30 31 or more

7. Do you smoke more in the first few hours after waking up than you do during the rest ofthe day?

No Yes

8. Do you smoke if you are ill and in bed most of the day?

No Yes

D. SMOKING HISTORY:

9. How old were you when you started smoking regularly?

10. How many cigarettes do you smoke on an average day ?

11. What brand do you smoke now?

12. How long have you been smoking at this level?

13. Do you use tobacco in any other form other than cigarettes? No Yes

If yes, please indicate the form and average daily amount used:

Form Average Daily Amount (s)

Pipes of tobacco Amount of bowlsCigars Amount of cigars

Chewing tobacco Amount of plugs

Cigarillos Amount of cigarillos

14. If you work, how much do you smoke during your workday?

15. Do you frequently wake-up during the night to smoke?


4/7



4

E. QUITTING HISTORY:

16. Have you tried to quit before? No Yes

If yes, which methods have you tried?(all that apply) Which methods were you most successfulwith? (all that apply)

Cold turkey Cold turkeyCutting down gradually Cutting down gradually

Self-help pamphlet Self-help pamphlet

Individual counseling Individual counseling

Support Group Support Group

Acupuncture Acupuncture

Hypnosis Hypnosis

Laser Laser

Nicotine Gum Nicotine Gum

Nicotine Patch Nicotine PatchNicotine Lozenge Nicotine Lozenge

Nicotine Inhaler Nicotine Inhaler

Zyban ZybanChampix Champix

Other (specify) Other (specify)

17. When was your last quit attempt?

Never tried to quit (skip to section F)

Within the last month

Within the last year

Over a year agoOver 5 years ago

18. Why did you stop at that time?

19. How long did you go without smoking that time?

Less than 1 day1 day to 1 weekLess than 2 weeks but more than 1 weekLess than 1 month but over 2 weeks

Less than 3 months but over 1 monthLess than 1 year but over 3 monthsMore than 1 year

20. Why did you start smoking again?

Craving to smoke became too strong

Needed it to cope with pressure and stress

Began smoking at a party or other social situationBegan smoking while drinking alcoholOther (please specify)


5/7



5

21. How many times have you quit smoking for more than 24hours?

22. What is the longest you have gone without smoking?

F. WHY I SMOKE(Why Test)Please read each statement, then check ()the box that matches how you feel aboutsmoking

Not at all Very much

1 2 3 4 5

A I smoke to keep myself from slowing down

B Handling a cigarette is part of theenjoyment of smoking it

C Smoking is pleasant and relaxing

D I light up a cigarette when I feel angryabout something

E When Im out of cigarettes, its near-tortureuntil I can get them

F I smoke automatically, without ever beingaware of it

G I smoke when other people around me aresmoking

H I smoke to perk myself up

I Part of enjoying smoking is preparing tolight up

J I get pleasure from smoking

K When I feel uncomfortable or upset, I lightup a cigarette

L Im very much aware of it when Im notsmoking a cigarette

M I often light up a cigarette while one is stillburning in the ashtray

N I smoke cigarettes with friends when Imhaving a good time

O When I smoke, part of my enjoyment iswatching the smoke as I exhale it

P I want a cigarette most often when I amcomfortable and relaxed

Q I smoke when Im blue and want to takemy mind off whats bothering me

R I get a real craving for a cigarette when Ihavent had one in a while

S Ive found a cigarette in my mouth andhavent remembered that it was there

T I always smoke when Im out with friendsat a party, bar, etc

U I smoke cigarettes to get a lift


6/7



6

G. YOUR FEELINGS AND PLANS ABOUT STOPPING SMOKING

23. Check the box which best describes you

I am not thinking about quitting, certainly not in the next 6 months.I am thinking about quitting in the next 6 months.I want to quit within the next month and I want to know more about how to do it.I have quit smoking for 6 months or less.I have quit smoking for over 6 months.

24. Importance: Circle the number that best measures how important it is for you to stopsmoking. (1 being not at alland 5 being very important)

1 2 3 4 5

25. Commitment: Circle the number that best measures how committed you are to stopsmoking. (1 being not very committedand 5 being very committed)

1 2 3 4 5

26. Confidence: Rate how confident you are that you will notsmoke in these situations:(1 being not at all confident that you wont smokeand 5 being extremely confidentthat you wont smoke)

1 2 3 4 5 With friends at a party

1 2 3 4 5 When I first get up in the morning

1 2 3 4 5 When I am very anxious and stressed

1 2 3 4 5 Over coffee while talking and relaxing

1 2 3 4 5 When I feel I need a lift

1 2 3 4 5 When I am very angry about something or someone

1 2 3 4 5 With my spouse or a close friend who is smoking

1 2 3 4 5 When I realize I havent smoked for a while

27. What benefits do you get from smoking?

28. What harm or negative effects has smoking caused you?

29. Why do you want to stop smoking?

30. What about quitting smoking would be hard for you?


7/7



7

31. Are you ready to set a date to quit smoking? No Yes

H. OTHER INFORMATION

32. Are you concerned that your weight will be affected as you quit smoking?

No Yes

Comments:

33. What physical activity do you do regularly?

Walking Jogging

Biking House workSwimming GardeningOther

34. Select the quit smoking method(s) you are interested in?

Self-help pamphletsIndividual counselingNicotine gumNicotine patchNicotine inhaler

Nicotine LozengeZyban /ChampixOther (specify)

Freedom of Information Collection Notice: Personal information is collected underthe statutory authority of the Health Protection and Promotion Act, R.S.O. 1990c.H.7, s.5. This information will be used to provide health services to individuals atthe Porcupine Health Unit Quit Smoking Clinic. Questions about this collectionshould be directed to Public Health Nurse at the clinic.

Signature of client Date

(Adapted from the Peel Public Health, Halton Regional Health Department, Toronto PublicHealth and the University of Massachusetts Medical School Quit Smoking Programs.)

September 2011 Ce document est disponible en franaisSubmit by e-mail

intakequestionnaireform_000

Documents