Date: [Date of encounter]
Patient: [Patient Name]
Reason for Visit:
Document the reason for the visit related to tobacco use, such as:
Initial tobacco use assessment
Follow-up for tobacco cessation attempt
Management of cravings or withdrawal symptoms
History of Present Illness:
Tobacco Use History:
Current tobacco use status (smoker, former smoker, never smoker)
Type of tobacco product(s) used (cigarettes, cigars, smokeless tobacco)
Smoking history (number of years smoked, pack-years) – for smokers and former smokers
Reason for starting tobacco use
Triggers for tobacco use (e.g., stress, social situations)
Quit Attempts:
Number of previous quit attempts
Methods used for quitting in the past (e.g., cold turkey, nicotine replacement therapy, medication)
Reasons for relapse (if applicable)
Current Motivation to Quit:
Assess the patient’s motivation to quit tobacco use on a scale (e.g., 1-10, with 10 being highly motivated).
Explore reasons for wanting to quit (e.g., health concerns, financial reasons, family)
Past Medical History:
Medical conditions potentially related to tobacco use (e.g., lung cancer, COPD, heart disease)
Current medications (some medications may interact with smoking cessation medications)
Social History:
Living situation (exposure to secondhand smoke)
Social support for quitting (e.g., family members who smoke, friends who are supportive)
Physical Exam:
Vital signs (may be normal or show signs of tobacco-related health problems).
Lung examination (may reveal wheezing or other abnormalities in smokers with COPD).
Assessment:
Current tobacco use status and dependence level.
Motivation to quit tobacco use.
Potential barriers to quitting (e.g., withdrawal symptoms, lack of support).
Consideration of health risks associated with continued tobacco use.
Plan:
Develop a Quit Plan: Collaborate with the patient to create a personalized quit plan that addresses their specific needs and preferences. This may involve:
Setting a quit date: Encourage a specific date in the near future for quitting tobacco use.
Discussing Smoking Cessation Medications:
Nicotine replacement therapy (NRT) – available in various forms (patches, gum, lozenges, inhalers, sprays) to help manage withdrawal symptoms.
Prescription medications (e.g., bupropion, varenicline) – may be considered for some patients, depending on individual factors and medical history.
Counseling and Support:
Individual or group counseling sessions can provide support, education, and coping strategies for quitting.
Referral to a tobacco cessation program or support groups can provide additional resources and encouragement.
Address Withdrawal Symptoms: Educate the patient about potential withdrawal symptoms (irritability, anxiety, difficulty concentrating) and offer strategies for managing them (e.g., exercise, relaxation techniques).
Follow-up: Schedule regular follow-up appointments to monitor progress, address challenges, and provide ongoing support.
Patient Education:
Educate the patient about the health benefits of quitting tobacco use and the risks of continued use.
Explain the different smoking cessation medications and their potential side effects.
Discuss the importance of social support for quitting and identify ways to build a support system.
Provide resources for quitting smoking (e.g., quitlines, online resources, support groups).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. The approach to tobacco use cessation should be individualized and consider the patient’s motivation, preferences, and medical history