Pharmacy Stop SmokingService - CSSS monitoring form

ALL MARKED (*) FIELDS ARE MANDATORY FOR SUBMISSION TO DEPARTMENT OF HEALTH

------SECTION 1------

1st Appointment

*Pharmacy Name
and Address:
Client I.D
(= client ID reference code on Stop Smoking Claim form) / *Client name:
(full name & title) / *DoB:
*Telephone No: / *Gender:
*Address
*Post Code:
*GP name & surgery
*Occupation:
(see sheet) / *Ethnicity:
(see sheet)

Pregnant: YES/NOBreastfeeding: YES/NO

Exempt from Prescription Charges: / YES/NO / *Quit Date:

Product

Type of licensed pharmacological support used (please tick all relevant boxes):

Single NRT / Combination NRT
Varenicline (Champix) / Bupropion (Zyban)
None

Where more than one pharmacological therapy has been used, were these:

Used at the same time
Used consecutively (ie. the client switched product as past of a single quit attempt

If NRT product used, which product:

Patch / Gum / Nasal spray
Mouth spray / Inhalator / Micro tabs
Lozenges / Oral strips

Use of unlicensed nicotine containing product (NCP):

Unlicensed NCP used? (ie. e-cigarette) / YES / NO
Used instead of licensed medication? / YES / NO
Used at the same time as licensed medication? / YES / NO
Used consecutively to licensed medication? / YES / NO

(ie. client switched product during quit attempt)

IConsent to treatment

I agree for my data to be shared with the Cumbria Stop Smoking Service

I am happy to be contacted by a member of the Stop Smoking Service

I declare I am not receiving stop smoking support from any other source

Consent given for text messages

Client Signature: ______Date: ______

------SECTION 2------

4 Week Follow Up

*Follow-Up Date:
(Must be between 25 and 42 days after quit date stated above)
*Date of Last Cigarette (if quit):
Medication Changed to:

*Has Client Quit Smoking?

YES(if yes see below) NOLost to Follow Up

CO Validation Confirmed (client has blown into CO monitor and has been confirmed as quit)

Once completed (after the 4 week follow-up consultation is complete)

please return the whole form (with the claim form) to:

Michelle Jasper, Contractor Services, Tenterfield,Brigsteer Road, KendalLA9 5EA

Updated 20.08.13