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Tobacco Screening Form: Initial Screening Second Screening Follow-Up Screening (A) Low (B) Medium (C) High

This document is a tobacco screening form that collects information from clients about their tobacco and nicotine use. It consists of 11 multiple choice questions that gather details such as current and past tobacco habits, attempts to quit, triggers for use, living situation, and readiness to quit. The form is used to assess clients and determine appropriate cessation counseling and resources.

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Chris Dubuque
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© © All Rights Reserved
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84 views1 page

Tobacco Screening Form: Initial Screening Second Screening Follow-Up Screening (A) Low (B) Medium (C) High

This document is a tobacco screening form that collects information from clients about their tobacco and nicotine use. It consists of 11 multiple choice questions that gather details such as current and past tobacco habits, attempts to quit, triggers for use, living situation, and readiness to quit. The form is used to assess clients and determine appropriate cessation counseling and resources.

Uploaded by

Chris Dubuque
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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TOBACCO SCREENING FORM

Client ID: _______________________ Date of Birth: _____ / _____ /____


Month Day Year
Date: _____ / _____ /________
Month Day Year

Race/Ethnicity: ________________ Counselor:________________________


CO VALUE ________ PPM __________( date)
 Initial Screening CO Range:
 Second Screening  (a) Low
 Follow-up Screening  (b) Medium
 (c) High

1. Which statements best describes your current tobacco use? (choose all that apply)
 I have never smoked cigarettes. (a) (Mark here if you have only tried smoking) Skip to Question 9
 I stopped smoking within the past year– I am not smoking (b) Skip to Question 9
 I dip, chew or use smokeless tobacco. (c)
 I smoke e-cigarettes/vapor. (d)
 I smoke regularly now – (e)
Number of cigarettes I smoked yesterday: 
2. How long have you used tobacco (or nicotine products - say which product and for how long):

3. Are there any changes in your use of tobacco (or nicotine products) recently:

4. How soon after you wake up do you usually use tobacco? (choose only one)
(a) 5 minutes or less ( b ) 6 to 30 minutes ( c) 31 to 59 minutes ( d) 1 to 2 hours ( e) Greater than 2 hours
5. How many attempts to quit have you made: _______
Date of your most recent quit attempt:____________
How long were you able to stay quit:______________
6. If you have tried quitting before what worked to help you:

What have you tried that did not work: ___________________________________________________________________

What were the reasons you went back to smoking:__________________________________________________________

7. Have you ever tried using nicotine replacement products: (a) No (b) Yes
If yes, what product(s) ___________________; how much did you use:__________ for how long did you use it:___________

8. How ready do you feel now to quit:


 (a) Not thinking about it
 (b) Thinking about it, not ready
 (c) Ready to quit (if ready, how confident do you feel about your ability to quit on 1 – 10 with 1 being
low):__________

9. How many cigarette smokers live in the same house with you? (choose only one)
(a) None (b) 1 (c) 2 or more
10. How is cigarette smoking handled where you live? (choose only one)
(a) No one smokes where I live – they smoke outside. (e) Don’t know
(b) People may only smoke in certain rooms where I live. (f) Refuse to say
(c) People may smoke anywhere I live.
11. How many of your family and friends are cigarette smokers? (choose only one)
(a) None (b) A few (c) Some (d) Most

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