CAMBRIDGESHIRECOMMUNITY PHARMACY STOP SMOKING MONITORING FORM

Pharmacy Stamp/Address / The information on this data sheet is for: Please circle appropriate
1-4 weeks data5-8 week data9-12 week data
Please return completed forms to:
Cambridgeshire County Council,
CAMQUIT, Public Health, Box No CC1318,
Castle Court, Castle Hill, Cambridge, CB3 0AP
Tel: 01223 703245 / For office use only:
Date received
Return of data fee (£15) Y/N
Client quit fee(£15) Y/N
CLIENT DETAILS
Surname / First Name / Mr/Mrs/Ms/Other
Address
Postcode / Contact No.
Date of Birth / Gender / Male / Female
GP surgery
NHS ID No / Pregnant Y / N / Breast feeding Y / N
Prescription Exemption Code / Ethnic Group Code / Occupation Code
HOW CLIENT HEARD ABOUT THE SERVICE: (please tick relevant box)
Health professional / Friend/relative / Marketing event / Web search
Radio advertising / In store promotion / Other (please specify)
Agreed quit date / An ‘agreed quit date’ is the date which the client chooses to stop smoking and is the start of the four week quit period.
Date seen / CO reading / Smoking status
S or NS / NRT SUPPLY
Brand / Type of NRT / Strength / Pack size
TREATMENT OUTCOME: Quit CO verified Quit self report Not Quit Lost to follow up
Total prescription charge paid (see overleaf)
For office use only: Total cost of NRT (minus prescription charge)
Adviser signature / Client signature (I confirm proper entitlement to exemption. I consent to treatment and follow-up and I understand the information on this form may be passed on to my GP and CAMQUIT).
PRECRIPTION EXEMPTION CODES
Ais under 16 years of age
Bis 16,17 or 18 and in full-time education
Cis 60 years of age or over
Dhas a valid maternity exemption certificate
Ehas a valid medical exemption certificate
Fhas a valid prescription pre-payment certificate
Ghas a valid War Pension exemption certificate
Lis named on a current HC2 charges certificate
Hgets Income Support or income-related Employment and Support Allowance
Kgets income-based Jobseeker’s Allowance
Mis entitled to, or named on, a valid NHS Tax Credit Exemption Certificate
Shas a partner who gets Pension Credit guarantee credit (PCGC)
ETHNIC GROUP CODES
1White – British12Black or Black British – Caribbean
2White – Irish13Black or Black British – African
3White – any other background14Black or Black British – any other Black background
4Mixed – White & Black Caribbean15Chinese
5Mixed – White & Black African16Turkish
6Mixed – White & Asian17Any other ethnic group
7Mixed – any other mixed background
8Asian or Asian British – Indian
9Asian or Asian British – Pakistani
10Asian or Asian British – Bangladeshi
11Asian or Asian British – any other Asian background
OCCUPATION CODESPlease enter one of the following codes to indicate the occupational classification of the service user. Use the job examples listed below to help you.
1Managerial & professional occupations 4Never worked or unemployed for over one year
2Intermediate occupations5Student, full time homemaker, retired
3Routine and manual occupations6 Not known or unable to code
**For people who have been unemployed for less than one year, please try to classify them according to their last occupation**
ProfessionalTeacherArtist
NurseSoftware Engineer
Social WorkerScientist
PolicemanDoctor
LawyerSenior Manager
AcademicConsultant / IntermediateSecretary/PANursery Nurse
AdministratorCall Centre Agent
Bank ClerkAuxiliary Nurse
Plumber, electricianShop Manager
GardenerSkilled technical
Train driveror craft occupations / Routine & ManualPostal WorkerLabourer
Machine OperativeCleaner
Catering AssistantFarm Worker
HGV Driver
Waiter/Waitress
Shop Assistant

PRESCRIPTION CHARGE

Clients are charged one item fee per product type per month e.g. Nicorette patches and Nicorette gum would incur two charges. However, Nicorette 15mg patch followed by 10mg patch would incur one charge.

Returning Data

When the client has set a quit date and been monitored at four weeks after that date please complete the form and have it ready to send in. As the stop smoking service reports monthly please ensure the forms you have ready with four week outcomes are sent by the 10th of each month.