Get Smoking Cessation Form

Filling out the Smoking Cessation Form online is an important step in your journey to quitting smoking. This guide provides clear and detailed instructions to help you navigate each section of the form effectively.

Follow the steps to complete your Smoking Cessation Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering your personal information, including your last name, first name, address, city, postal code, telephone number, and date of birth in the provided fields.
3. Next, fill in the physician’s name and the date of the follow-up consultation.
4. Indicate your smoking status by answering whether you have used any form of tobacco in the past 7 days and specify if you smoke within 30 minutes of waking.
5. If applicable, provide details on your quit smoking medication by selecting whether you are still using it, noting any type and dosage. Include any questions or concerns about the medication if relevant.
6. Assess withdrawal and side effects by rating symptoms such as nausea, headache, and sleep disturbances on the severity scale from mild [0] to severe [4].
7. Reflect on any mood changes you or those close to you have noticed since you quit smoking, using the same severity rating scale.
8. Indicate your daily caffeine intake by selecting the number of caffeinated beverages you consume.
9. Answer if you have experienced any cravings to smoke and provide a brief assessment of relapse risk based on past situations.
10. Summarize your quit plan, including medications management and relapse prevention notes. Fill out the follow-up plan regarding the number of weeks as necessary.
11. Review all entered information for accuracy, then proceed to save changes, download, print, or share your completed form as needed.

Start filling out your Smoking Cessation Form online today to take a significant step towards a healthier future.