Smoking Cessation RAF

Personal Medical History

Do you have any recent or past medical history of note? *

Details (reconfirm each appointment) *

Have you had a serious reaction to a varenicline before? *

Details (reconfirm each appointment) *

Have you received advice from a smoking cessation counsellor before? *

Details (reconfirm each appointment) *

Have you tried to quit using nicotine replacement therapy (NRT) before? *

Details (reconfirm each appointment) *

Are you on any medicines? Such as antiepileptics, antidepressants, antipsychotics, B-blockers, type 1C antiarrhythmics, cimetidine, theophylline or warfarin? *

Details (reconfirm each appointment) *

Do you have a medical history of any of the following: renal / kidney problems, psychiatric illnesses (with symptoms of irritability or depression), myocardial infarction (MI) or risk factors for MI? *

Details (reconfirm each appointment) *

Precautions

Do you understand that you must seek prompt medical advice if you develop agitation, depressed mood, or suicidal thoughts whilst taking varenicline? *

Details (reconfirm each appointment) *

Do you understand that varenicline may affect your ability to perform tasks that require judgement or motor and cognitive skills? *

Details (reconfirm each appointment) *

Motivation

Do you feel sufficiently motivated to quit smoking (willing to set a quit date between days 8 and 14 of starting treatment)? *

Details (reconfirm each appointment) *

Do you agree to receive weekly face-to-face motivational support for the first four weeks at least? *

Details (reconfirm each appointment) *

WOMEN ONLY

Are you pregnant or planning a pregnancy? *

Details (reconfirm each appointment) *

Are you breastfeeding? *

Details (reconfirm each appointment) *

Write below any further information which may be relevant e.g. medicines taking, conditions, concerns...

Patient's Personal Details

Title

First Name

Last Name

Telephone

Gender

Date of birth

Patient Address

NHS No. (If Known)

GP Name and Address

GP Telephone (If Known)

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Product total

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Grand total

£666.00

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Smoking Cessation RAF

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