Brief Tobacco Use Screening Sheet
Patient Information
Name:
Date:
Date of Birth:
Tobacco Use Status
Current User
Former User
Never Used
If Current or Former User:
Types of Tobacco Used:
Cigarettes
Cigars
Smokeless
E-Cigarettes
Other
Amount per day:
Years of use:
If quit, quit date:
Ready to Quit?
Yes
No
Comments/Notes: