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Stop Smoking Assessment

Stop Smoking Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Stop Smoking Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Do you feel a strong craving or urge to smoke whenever you try to cut down or stop smoking?*

Yes

No

Please provide more information below.*

Have you experienced withdrawal symptoms, such as irritability, anxiety, or difficulty concentrating, when attempting to quit smoking in the past?*

Yes

No

Please provide more information below.*

Does smoking play a significant role in your daily routines or activities?*

Yes

No

Please provide more information below.*

Have you tried to quit smoking before but relapsed?*

Yes

No

Please provide more information below.*

Do you rely on smoking as a means to manage stress or negative emotions?*

Yes

No

Please provide more information below.*

Health

Are you currently using any form of nicotine replacement therapy (NRT), such as patches, gum, or lozenges?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any pre-existing medical conditions, such as heart disease, high blood pressure, or diabetes, that could be affected by smoking or the process of quitting?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant, planning to become pregnant, or breastfeeding, as this may influence the choice of stop-smoking treatments available to you?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you taking any medications that might interact with stop-smoking aids or treatments?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you been diagnosed with any mental health conditions, such as depression or anxiety, that could be influenced by quitting smoking?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to provide a comprehensive understanding of the patient's readiness to quit smoking, their smoking habits, and any health considerations that need to be taken into account when prescribing treatments.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Comments

This field is for validation purposes and should be left unchanged.

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