Quit Smoking Readiness Assessment – Patient’s Use
Lung related problems: Yes / No _____ Past Seizure history: Yes / No _____ Cancer: Yes / No; _____ ... Stress Other smokers Drinking alcohol Nicotine urges Smoking cues Availability of cigarettes Weight gain Other Other Strategies to overcome these challenges: Delay tactic Distraction strategies (e.g., walking) Places to avoid Places to go (where smoking prohibited) Use quit smoking help-lines ... ................
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