Smoking Cessation Risk Assessment
Patient Information
Name
Date of Birth
Medical Record Number
Smoking History
Current Smoking Status
Current Smoker
Former Smoker
Never Smoked
Number of cigarettes per day
Years of smoking
Previous Quit Attempts (number and duration)
Nicotine Dependence
Time to first cigarette after waking
Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes
Cravings intensity
Mild
Moderate
Severe
Motivation & Readiness
Stage of readiness to quit
Not Interested
Considering
Ready
Recently Quit
Motivation to quit (0-10)
Main reasons for quitting
Risk Factors & Co-morbidities
Relevant medical/psychiatric history
Medications
Other substances used
Support & Barriers
Key support persons
Possible barriers to quitting
Preferred methods of support
Assessment Notes