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UNIVERSITY OF COLORADO HOSPITAL PATIENT INTAKE FORM Tobacco Use History Tobacco Use? Packs/Day (circle one)0.511.52Types of Tobacco Used: (circle all that apply)OtherCigarettes Pequot Date:Years UsedSmokeless
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How to fill out tobacco use history
How to fill out tobacco use history
01
Start by gathering all the necessary information about your tobacco use history.
02
Begin by documenting the start and end dates of your tobacco use.
03
Specify the type of tobacco product you have used, such as cigarettes, cigars, chewing tobacco, or pipe tobacco.
04
Provide details about the frequency and quantity of tobacco use, including the number of cigarettes smoked per day or the amount of chewing tobacco consumed.
05
Remember to mention any attempts you have made to quit tobacco use in the past.
06
Include any relevant medical conditions or complications resulting from tobacco use.
07
Finally, sign and date the tobacco use history form to validate the information provided.
Who needs tobacco use history?
01
Tobacco use history is required by various entities and organizations, including:
02
- Healthcare providers to assess smoking-related health risks and determine appropriate treatment plans.
03
- Insurance companies to determine premium rates for life, health, or disability insurance policies.
04
- Researchers studying the impact of tobacco use on public health.
05
- Employers implementing workplace health initiatives or conducting health screenings.
06
- Government agencies developing tobacco control policies and strategies.
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What is tobacco use history?
Tobacco use history is a record of an individual's past and current tobacco use, including smoking, chewing, or any other form of tobacco consumption.
Who is required to file tobacco use history?
All individuals who have used tobacco products in the past are required to file tobacco use history.
How to fill out tobacco use history?
To fill out tobacco use history, an individual must provide details about their tobacco use, including frequency, duration, and type of tobacco product used.
What is the purpose of tobacco use history?
The purpose of tobacco use history is to assess an individual's risk of tobacco-related health complications and to provide appropriate interventions.
What information must be reported on tobacco use history?
Information such as frequency of tobacco use, duration of tobacco use, type of tobacco product used, and any attempts to quit smoking must be reported on tobacco use history.
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