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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