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Smoking Cessation Intake Form

Smoking Cessation Intake Form 2026

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The document consists of a Smoking Cessation Intake Form and a HIPAA Privacy Agreement from Abundant Health Holistic Center. The intake form collects personal information, smoking habits, previous quit attempts, health concerns related to smoking, and support systems for quitting. It also includes sections on mental health history and other addictions. The HIPAA agreement outlines the patient's rights regarding the restriction of their protected health information (PHI) and acknowledges receipt of privacy practices.

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Click ‘Get Form’ to open the Smoking Cessation Intake Form in the editor.
Begin by entering your personal information, including your name, date, address, and contact numbers. Ensure accuracy for effective communication.
Indicate your tobacco usage by specifying the products you currently use and how long you've been using them. This helps in tailoring your cessation plan.
Reflect on your past attempts to quit smoking. Fill in details about previous methods used and reasons for challenges faced. This insight is crucial for developing a supportive strategy.
Answer health-related questions honestly, including any concerns linked to smoking and mental health history. This information is vital for comprehensive care.
Rate your desire to stop smoking at this time by circling the appropriate option provided in the form.
Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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2010	4.9 Satisfied (29 Votes)

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What are the 5r model of smoking cessation?

The 5 Rs: Relevance, Risks, Rewards, Roadblocks, and Repetition. are designed to motivate smokers who are unwilling to quit at this time. Smokers may be unwilling to quit due to misinformation, concern about the effects of quitting or demoralization because of previous unsuccessful quit attempts.

What are the 5 Rs of smoking cessation?

The clinician can motivate patients to consider a quit attempt with the 5 Rs: Relevance, Risks, Rewards, Roadblocks, and Repetition. Relevance - Encourage the patient to indicate why quitting is personally relevant.

What are the 5s of smoking cessation?

Smoking remains the leading cause of preventable mortality in the US. The national clinical guideline recommends an intervention for tobacco use known as the 5-As (Ask, Advise, Assess, Assist, and Arrange).

How to document smoking cessation?

As such, the following items should be documented in the medical record: The patient/clients willingness to attempt to quit. What was discussed during counseling/treatment planning. Amount of time spent counseling the patient/client. Tobacco use. Advice to quit and impact of smoking provided to patient.

What are the 4 Ds of smoking cessation?

The four Ds are variously set out as: Delay: for a few minutes and the urge will pass. Drink water: sip it slowly. Deep breathe: take three slow, deep breaths. Do something else: to take your mind off smoking.

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