Get Smoking Cessation Intake Form

Completing the Smoking Cessation Intake Form online is an important step in your journey to quit smoking. This guide will provide you with clear, step-by-step instructions to effortlessly fill out the form and ensure that you provide all necessary information.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Start by entering your full name in the designated area, followed by the current date. This information is essential for identifying your submission.
3. Next, fill in your complete address, including city, state, and zip code. Accurate address information helps in establishing communication.
4. Provide your phone numbers in the respective fields: daytime, evening, and cell phone. Make sure to indicate whether you would like to receive messages.
5. In the section concerning tobacco use, specify what products you currently use, how long you have been using them, and your average daily consumption over the last month.
6. Indicate if you have attempted to quit in the past and share the methods you have used, along with the reasons for previous failures or resumption of use.
7. Answer the questions regarding any recommendations from doctors about quitting smoking, as well as any related health concerns you might have.
8. Respond to inquiries about your mental health history, including any treatments for anxiety or depression. This will help in tailoring your cessation plan.
9. Indicate when you typically smoke by circling the appropriate times and listing any specific behaviors associated with your smoking habits.
10. Rate your desire to quit smoking at this moment by circling the option that best describes your motivation.
11. Provide information about other smokers in your household and the level of support you feel from family and friends regarding your quitting journey.
12. Outline your reasons for wanting to quit smoking at this time and list any other addictions or habits you may have.
13. Document any medications, herbs, or supplements you are currently taking to ensure a comprehensive health overview.
14. Include any additional questions or concerns you might have in the final section of the form.
15. Finally, review all the information you have entered for accuracy. Once confirmed, sign and date the form before saving your changes, and choose to download, print, or share the completed document.

Start your journey to a smoke-free life by completing the Smoking Cessation Intake Form online today.