Smoking cessation form 2026

1. Click ‘Get Form’ to open the smoking cessation follow-up consult form in the editor.
2. Begin by entering your Patient ID, Last Name, First Name, Address, City, Postal Code, Telephone number, and Date of Birth in the designated fields.
3. In the 'Assess Smoking Status' section, indicate whether you have used any form of tobacco in the past 7 days by selecting 'Yes' or 'No'. If applicable, specify how many cigarettes you smoke per day.
4. For 'Medications Management', confirm if you are still using the recommended quit smoking medication. Provide details about the type and dosage if applicable.
5. Rate any withdrawal symptoms you've experienced on a scale from Mild [0] to Severe [4]. This includes symptoms like nausea and headache.
6. In the 'Mood Changes' section, rate any mood changes noticed since quitting on a similar scale. Include feelings such as anger or anxiety.
7. Complete sections on caffeine use and cravings by providing relevant information regarding your daily caffeine intake and any cravings to smoke.
8. Finally, summarize your quit plan including medications management and relapse prevention notes before saving your completed form.

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