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PHARMACY SMOKING CESSATION MONITORING FORM 201516 Smoking Cessation Monitoring Form 2015×16 All shaded sections MUST be completed. Smoking cessation contract only enables payment for a fully completed

How to fill out smoking cessation monitoring form

How to fill out a smoking cessation monitoring form:

1. Start by filling out your personal information section, including your name, date of birth, and contact information.
2. Indicate the date you started your smoking cessation program and the specific program you are participating in.
3. In the next section, record your smoking history, including the number of cigarettes or tobacco products you used to consume per day, and the duration of your smoking habit.
4. Provide information on any previous attempts to quit smoking and note the methods or therapies you have used in the past.
5. If you are currently using any medication or nicotine replacement therapy (such as patches, gum, or inhalers) to aid in your smoking cessation, specify the type and dosage in the respective section.
6. Record any side effects or concerns you may be experiencing during your smoking cessation journey in the provided space or checkbox.
7. Make sure to accurately document the number of days since you last smoked and any slip-ups or relapses you may have experienced.
8. If you are meeting regularly with a healthcare professional or participating in support group sessions, include information about these sessions in the relevant section.
9. Finally, read through the form carefully and sign and date it to confirm that the information provided is accurate and complete.

Who needs smoking cessation monitoring form?

1. Individuals undergoing a smoking cessation program or who have recently quit smoking may need to fill out a smoking cessation monitoring form.
2. Healthcare professionals, including doctors, nurses, or therapists, who are monitoring and providing support to individuals on their journey to quit smoking may also require the use of a smoking cessation monitoring form.
3. Research institutions or organizations conducting studies or surveys on smoking cessation may also use such forms to collect data and monitor the progress of participants.

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