Download Table 4 Tobacco Use Screen1

Table 4 Tobacco Use Screen1
Your overall health is important to us. We would appreciate your answers to the following questions.
PLEASE COMPLETE THE FOLLOWING QUESTIONS:
1. Have you used any form of tobacco in the past 12 months?
2. Have you used any form of tobacco in the last 7 days?
3. How many years have you been using tobacco?
4. What form(s) of tobacco do you typically use?
5. How soon after you wake up to you first use tobacco?
6. What has been the longest period of time that you have
been able to abstain from using tobacco?
ANSWER HERE
 Yes
 No – please skip to question 11
 Yes – please continue
 No – please continue
_______________ years
 Cigarettes
_______________amount daily or
_______________amount monthly
 Smokeless tobacco (e.g. chew, spit, snus)
_______________ amount daily or
_______________ amount monthly
 Other (e.g. cigar, waterpipe or bidi)
_______________ amount daily or
_______________ amount monthly
 Within 5 minutes
 6-30 minutes
 31-60 minutes
 After one hour
________________________________
(hours, days, weeks or months)
7. What, if anything, have you used in the past to help you
 Nicotine replacement (e.g. patch, gum,
abstain from using tobacco?
lozenge or inhaler)
 Combinations of medications
 Bupropion (Zyban or Wellbutrin)
 Varenicline (Champix)
8. On a scale of 1 to 10, how important is it to you to stop using tobacco? (please circle)
Not important 1 2 3
4
5
6
7
8
9 10
Very important
9. On a scale of 1 to 10, how confident are you that you are able to stop using tobacco? (please circle) 1
Not confident 1 2 3
4
5
6
7
8
9 10
Confident
10. Have you ever noticed a change in your mood when you
 Yes
have abstained from using tobacco in the past?
 No
11. Over the last 2 weeks, how often have you been bothered
by little interest or pleasure doing things?
_______________________________
12. Over the last 2 weeks, how often have you been bothered
by feeling down, depressed or hopeless? 2
_______________________________
For Physician Use Only
PCN Tobacco Cessation Classes
PCN Pharmacist/Nurse
13. Have you ever received treatment for your mood?
14. Have you ever attempted suicide?
15. Have you ever been admitted to a hospital for psychiatric
care?
1
2






Yes
No
Yes
No
Yes
No
Q8 & Q9 from Millner WR & Rollnick S (2002). Motivational Interviewing: Preparing People for Change.New York: Guildford.
Q11 & Q12 are from Spitzer RL, Williams, JB, Kroenke et al (1999) Patient Health Questionnaire (PHQ 2)
Tobacco Screen 1
PLEASE COMPLETE THE FOLLOWING QUESTIONS:
1. Have you used any form of tobacco in the past 12 months?
2. Have you used any form of tobacco in the last 7 days?
3. How many years have you been using tobacco?
4. What form(s) of tobacco do you typically use?
5. How soon after you wake up to you first use tobacco?
6. What has been the longest period of time that you have been
able to abstain from using tobacco?
7. What, if anything, have you used in the past to help you abstain
from using tobacco?
ANSWER HERE




Yes
No – please skip to question 11
Yes – please continue
No – please continue
_______________ years
 Cigarettes
_______________amount daily or
_______________amount monthly
 Smokeless tobacco (e.g. chew, spit, snus)
_______________ amount daily or
_______________ amount monthly
 Other (e.g. cigar, waterpipe or bidi)
_______________ amount daily or
_______________ amount monthly
 Within 5 minutes
 6-30 minutes
 31-60 minutes
 After one hour
________________________________
(hours, days, weeks or months)
 Nicotine replacement (e.g. patch, gum, lozenge or
inhaler)
 Combinations of medications
 Bupropion (Zyban or Wellbutrin)
 Varenicline (Champix)
8. On a scale of 1 to 10, how important is it to you to abstain from tobacco use? (please circle)
Not important 1 2 3
4
5
6
7
8
9 10
Very important
2
9. On a scale of 1 to 10, how confident are you in your ability to abstain from tobacco? (please circle)
Not confident 1 2 3
4
5
6
7
8
9 10
Confident
10. Have you ever noticed a change in your mood when you have
abstained from using tobacco in the past?
11. Over the last 2 weeks, how often have you been bothered by
little interest or pleasure doing things?
12. Over the last 2 weeks, how often have you been bothered by
3
feeling down, depressed or hopeless?
13. Have you ever received treatment for your mood?
14. Have you ever attempted suicide?
15. Have you ever been admitted to a hospital for psychiatric
care?


Yes
No
_______________________________






_______________________________
Yes
No
Yes
No
Yes
No
This screener was inspired by the work of Sophia Papadakis and the Ottawa Heart Model. Papadakis S (2007). Integrating smoking
cessation into routine primary care practice: identifying effective strategies for your practice. Smoking Cessation Rounds 1-9.
2
Q8 & Q9 from Millner WR & Rollnick S (2002). Motivational Interviewing: Preparing People for Change.New York: Guildford.
3
Q11 & Q12 are from Spitzer RL, Williams, JB, Kroenke et al (1999) Patient Health Questionnaire (PHQ 2)
1
Tobacco Screen 1
PLEASE COMPLETE THE FOLLOWING QUESTIONS:
1. Have you used any form of tobacco in the past 12
months?
2. Have you used any form of tobacco in the last 7 days?
3. How many years have you been using tobacco?
4. What form(s) of tobacco do you typically use?
5. How soon after you wake up to you first use tobacco?
6. What has been the longest period of time that you have
been able to stop using tobacco?
7. What, if anything, have you used in the past to help you
stop using tobacco?
ANSWER HERE
 Yes
 No – please skip to question 11
 Yes – please continue
 No – please continue
_______________ years
 Cigarettes
_______________amount daily or
_______________amount monthly
 Smokeless tobacco (e.g. chew, spit, snus)
_______________ amount daily or
_______________ amount monthly
 Other (e.g. cigar, waterpipe or bidi)
_______________ amount daily or
_______________ amount monthly
 Within 5 minutes
 6-30 minutes
 31-60 minutes
 After one hour
________________________________
(hours, days, weeks or months)
 Nicotine replacement (e.g. patch, gum, lozenge
or inhaler)
 Combinations of medications
 Bupropion (Zyban or Wellbutrin)
 Varenicline (Champix)
8. On a scale of 1 to 10, how important is it to you to stop tobacco use? (please circle)
Not important 1 2 3
4
5
6
7
8
9 10
Very important
9. On a scale of 1 to 10, how confident are you in your ability to stop using tobacco? (please circle)
Not confident 1 2 3
4
5
6
7
8
9 10
Confident
10. Have you ever noticed a change in your mood when you
have abstained from using tobacco in the past?
11. Over the last 2 weeks, how often have you been
bothered by little interest or pleasure doing things?
12. Over the last 2 weeks, how often have you been
3
bothered by feeling down, depressed or hopeless?
2
 Yes
 No
_______________________________
_______________________________
This screener was inspired by the work of Sophia Papadakis and the Ottawa Heart Model. Papadakis S (2007). Integrating smoking
cessation into routine primary care practice: identifying effective strategies for your practice. Smoking Cessation Rounds 1-9.
2
Q8 & Q9 from Millner WR & Rollnick S (2002). Motivational Interviewing: Preparing People for Change.New York: Guildford.
3
Q11 & Q12 are from Spitzer RL, Williams, JB, Kroenke et al (1999) Patient Health Questionnaire (PHQ 2)
1
Physician name____________________
Date: ___________________
PLEASE COMPLETE THE FOLLOWING QUESTIONS
1. Have you used any form of tobacco in the past 12
months? (answer on column to right)
2. Have you used any form of tobacco in the last 7
days?
3. How many years have you been using tobacco?
4. What form(s) of tobacco do you typically use?
ANSWER HERE
 Yes (continue to
question 2)
 Yes-Continue
5. How soon after you wake up to you first use
tobacco?
 Within 5 minutes
 6-30 minutes
 31-60 minutes
 After one hour
_______________________________
(hours, days, weeks or months)
 Nicotine replacement (e.g. patch, gum,
6. What has been the longest period of time that you
have been able to stop using tobacco?
7. What, if anything, have you used in the past to help
you abstain from using tobacco?
 No-STOP,
thank you
 No-Continue
________________years
 Cigarettes
_______________amount daily or
_______________amount monthly
 Smokeless tobacco (e.g. chew, spit, snus)
_______________ amount daily or
_______________ amount monthly
 Other (e.g. cigar, waterpipe or bidi)
_______________ amount daily or
_______________ amount monthly
lozenge or inhaler)
 Combinations of medications
 Bupropion (Zyban or Wellbutrin)
 Varenicline (Champix)
8. On a scale of 1 to 10, how important is it to you to stop using tobacco use? (please circle)
Not important 1
2
3
4
5
6
7
8
9
10
Very important
9. On a scale of 1 to 10, how confident are you that you can stop using tobacco? (please circle)
Not confident 1
2
3
4
5
6
7
8
9
10
Confident
10. Have you ever noticed a change in your mood when you

Yes
 No
have abstained from using tobacco in the past?

Not at all
11. Over the last 2 weeks, how often have you been bothered by

Several
days
little interest or pleasure doing things?

More than half the days

Nearly every day




12. Over the last 2 weeks, how often have you been bothered by
feeling down, depressed or hopeless?
For Physician Use Only
Advised to stop tobacco
Tobacco Cessation Counseling
Telephone F/U Only
PHQ-9 or HAM-D 7 administered




Yes
Yes
Yes
Yes




No
No
No
No
Not at all
Several days
More than half the days
Nearly every day