These files and forms are designed not only to simplify the business
of collecting information from clients in a structured way; but
also to promote clinical good practice. All these documents have
been developed and piloted over a number of years with thousands
of smokers.
These files and forms are available to be downloaded (adapted
if necessary) and used by members of the SCSRN.
| Questionnaires |
 |
Demographic
questionnaire |
download |
|
Smoking status
questions |
download |
|
Hand-rolled
cigarette questions |
download |
|
Suitability
for Medication Checklist |
download |
|
Postal (pre-quit)
questionnaire |
download |
|
Clinic session questionnaires
(quit date) |
download |
|
Post-quit questionnaires |
download |
|
Clinic session questionnaires
(week 1) |
download |
|
Clinic session
questionnaires (week 2) |
download |
|
Clinic session questionnaires
(week 3) |
download |
|
Clinic session
questionnaires (week 4) |
download |
|
Clinic session questionnaires
(week 52) |
download |
|
Client File
(Community Advisors) |
download |
| GP letters |
|
Standard Champix prescription request: no cautions |
download |
|
Standard Champix prescription request: cautions |
download |
|
Standard Zyban prescription
request: no cautions |
download |
|
Standard Zyban prescription request: cautions |
download |
|
Standard NRT prescription
request: no cautions |
download |
|
Standard NRT prescription request: cautions |
download |
|
Standard NRT prescription
request: pregnancy |
download |
|
Standard NRT prescription request: breastfeeding |
download |
|
Standard Champix repeat prescription request - abstinent |
download |
|
Standard Champix repeat prescription request - not abstinent |
download |
|
Standard Zyban repeat
prescription request - abstinent |
download |
|
Standard Zyban repeat
prescription request - not abstinent |
download |
|
Standard NRT repeat
prescription request- abstinent |
download |
|
Standard NRT repeat
prescription request- not abstinent |
download |
|
Standard End of treatment
- continuation of prescribing request |
download |
