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CLINICAL TOOLS (return to top)
The following are questionnaires and databases that can be incorporated into a patient's chart or used to monitor quality. For more information and additional tools regarding quality improvement, please click here. The questionnaires here are tailored to assessing the teen’s risk of relapse and satisfaction with having successfully quit. |
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Tracking Form
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Patient Tracking Form
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This tracking form records the patient’s stage of change, actions taken by the provider, actions taken by the patient, and any provider comments concerning a tobacco use discussion during an appointment. It can be in a patient’s chart for future reference and to track movement along the
stages of change.
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PATIENT HANDOUTS (return to top)
The following are informational forms that clinicians can hand to patients or parents. They can be edited or printed on your practice letterhead, although we cannot vouch for the accuracy of information once they are altered. These informational handouts were designed for the teenager who is staying tobacco free. |
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Exercise Prescription
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This worksheet provides information and tips for a teenager to create and implement a plan for regular cardiovascular exercise. Many teenagers who have not engaged in regular cardiovascular exercise may misinterpret their body’s response to increased activity. This “prescription” uses heart rate as a guide to monitoring exercise effectiveness. It also offers ideas for making exercise fun. This can be a central component of building alternative coping methods to tobacco use. |
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List of Website Resources for Teens Who Are Staying Tobacco Free
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This document can be given to the patient by a provider who wishes to direct him or her to the websites and links listed in the following section, allowing the teen to explore and utilize these web resources on his or her own time or between visits. Description language has been changed for the teen audience. |
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Mood Journal
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This journal template can be printed and copies for the teenager to track how their mood is affected by daily events and their capacity to practice effective coping methods. It can help them to correlate stress, mood, and coping. |
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Referral and Follow Up Form
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This document contains a list of possible referrals and follow-up tasks (worksheets and journals) for the teen to complete or pursue after a provider visit. The document already lists the information for the PA Quitline and the DeterminedToQuit website, but the provider can insert individual counseling and local resources in the spaces provided. |
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WEBSITES (return to top)
The following are direct links to tools and solutions from websites other than HelpTeensQuit. By clicking on the link, you will be taken directly to the clinical resource that may be helpful for a teen who is staying tobacco free. For a listing of homepage addresses for all of the websites referenced by HelpTeensQuit, please click here. |
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Patient Website
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Determined to Quit: Staying Tobacco Free
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This page and its links provide strategies for adopting a smoke-free lifestyle and dealing with cravings. Teens can also find a list of 101 things to do besides smoking for coping ideas, as well as a link to fun online games for distraction during cravings. Website by the Commonwealth of Pennsylvania. |
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Determined to Quit: Support and Resources
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This page provides personal quit stories, telephone resources, state and national websites, and books about quitting. Website by the Commonwealth of Pennsylvania. |
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TeenQuit: Crave Control
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This page contains a list of 30 things to do instead of smoking and as a distraction when cravings strike. Website corresponds to the ASCENT program. |
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TeenQuit: Frequently Asked Questions
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This page lists common questions and concerns about quitting smoking and living a tobacco-free, providing information or solutions to help. Website corresponds to the ASCENT program. |
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TeenQuit: Know Your Stats
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This page allows the teen to enter his or her average cigarettes per day and hypothetical quit date and the website will calculate the number of future cigarettes smoked, amount of minutes lost from life from smoking future cigarettes, average amount of money spent on future cigarettes, and offer financially-equivalent alternative activities. Website corresponds to the ASCENT program. |
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TeenQuit: Stressors Quiz
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This page contains a checklist of common stressors that teens experience and can help a teen recognize which stressors affect him or her the most. After completion, the teen is directed to aspects of the TeenQuit website that address selected stressors. Website corresponds to the ASCENT program. |
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REFERRAL (return to top)
We encourage you to contact your local programs to find out whether they are accepting referrals and if their program is right for your patient. Additionally, mental health professionals may be able to offer support with any effects on mood or behavioral problems that are exacerbated by quitting. For a listing of local tobacco cessation programs click here. |
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