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Appearance Assessment

Smoking Perceived Changes on Health and Appearance


Please take a moment on answering the questions.Kindly fill up necessary information and check Date: the following items as they apply to you. Name: Age: Years smoking: Color: SKIN Number of cigarettes/ day: Texture: Even Rough Elasticity Sagging Even Color Dull Shiny Texture Smooth Rough

Integrity Evenly colored Dull Mottled Intact Redenned Thickness Moisture Wrinkles Thinned Thickened Moist Dry Prominent Few lines No wrinkling observed Thickness Thinned Thickened Lines Prominent Few lines No wrinkling bev obered Texture Rough Silky Moisture Moist Dry
Evenly distributed Presence of hair loss

HAIR

Distribution

LIPS EYES TEETH

Color Dark toned Warm toned

(Q042A see reverse) Visit # 1 Counselling

PATTERN OF SMOKING: Harder to quit if: smokes >15 cigs/day, <1 wk smoke free in past year, started <16 yrs of age Notes/Comments:

Date:

Age started to smoke: Time of 1st cigarette after awakening (e.g. 30 min) Date of last quit attempt: Duration of quit attempt: Reason for relapse (or N/A): PREVIOUS MEDICATION USE: Comments: QUIT PLAN: Already quit? Yes No Nicotine Gum Reinforcement Yes (see reverse) Nicotine Gum

Nicotine Patch

Nicotine Inhaler

Bupropion HCL

Ready to set a quit date? Yes No Uncertain Nicotine Patch Intensive Intervention Nicotine Inhaler Withdrawal symptoms No

Quit Date (if applicable): Bupropion HCL Not required

Consider Pharmacotherapy Follow-up Relapse Prevention (see over) Referral to Community Smoking Cessation Program

PATTERN OF SMOKING: Harder to quit if: smokes >15 cigs/day, <1 wk smoke free in past year, started <16 yrs of age Current smoking status: Time of 1 cigarette after awakening (e.g. 30 min) Date of last quit attempt: Duration of quit attempt: Reason for relapse (or N/A): MEDICATION USE DURING QUIT ATTEMPT: Comments: QUIT PLAN: Consider/Reinforce Pharmacotherapy Ongoing Follow-up - Relapse Prevention (see over) Referral to Community Smoking Cessation Program Already quit? Yes No Nicotine Gum Reinforcement Yes (see reverse) Nicotine Gum
st

Date: st (Should be within 1 month of 1 counselling visit) Notes/Comments:

Nicotine Patch

Nicotine Inhaler

Bupropion HCL

Ready to set a quit date? Yes No Uncertain Nicotine Patch Intensive Intervention

Quit Date (if applicable): Bupropion HCL Not required

Nicotine Inhaler Withdrawal symptoms No