Get the free Quit Clinic Intake Form - Porcupine Health Unit
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File# PORCUPINE HEALTH UNIT QUIT SMOKING CLINIC INTAKE QUESTIONNAIRE A. GENERAL INFORMATION: Name: Health Card Number: Date of Birth (year/month/day):Sex:FemaleMaleMailing Address & Postal Code: Contact
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How to fill out quit clinic intake form
How to fill out quit clinic intake form
01
Start by reading the instructions at the top of the intake form.
02
Provide your personal information, such as your name, date of birth, and contact details.
03
Answer the questions about your medical history, including any previous treatments or medications.
04
Provide information about your smoking habits, such as how many cigarettes you smoke per day.
05
Answer questions about any previous attempts to quit smoking and the methods you have used.
06
If you have any current medical conditions or allergies, make sure to specify them on the form.
07
Finally, review the form to ensure all the information provided is accurate and complete before signing and submitting it.
Who needs quit clinic intake form?
01
Anyone who is seeking help from a quit clinic to quit smoking needs to fill out the quit clinic intake form.
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What is quit clinic intake form?
The quit clinic intake form is a form used to gather information from individuals who are interested in enrolling in a quit smoking program at a clinic.
Who is required to file quit clinic intake form?
Individuals who want to participate in a quit smoking program at a clinic are required to file the quit clinic intake form.
How to fill out quit clinic intake form?
The quit clinic intake form can be filled out by providing personal information, smoking history, reasons for wanting to quit, and other relevant details requested on the form.
What is the purpose of quit clinic intake form?
The purpose of the quit clinic intake form is to gather necessary information about individuals who are seeking help to quit smoking, in order to tailor the program to their specific needs.
What information must be reported on quit clinic intake form?
The quit clinic intake form may require information such as personal details, smoking habits, health history, reasons for wanting to quit, and contact information.
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