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CLINICAL TOOLS
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 teenager's willingness to change and the perceived risks and benefits of their tobacco use. |
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Guide to Nicotine Replacement Therapies
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This brief guide to nicotine therapies is tailored to recommendations and the needs of teenagers. |
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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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Questionnaire
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Tobacco History Questionnaire
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This questionnaire is designed to assess the length of tobacco use, level of addiction, triggers, perceived benefits of tobacco use, number of previous quit attempts and quit methods, and personal challenges of quitting of a patient who reported tobacco use previously or through the Tobacco Use Questionnaire. It can be given directly to patents for completion or used by the provider as guidance for gathering information. |
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PATIENT HANDOUTS
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 with the teenager who is not interested in quitting in mind. |
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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 Have No Interest in Quitting
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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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List of Websites for Teens Who Relapse
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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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Why Should I Quit?
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This worksheet is designed to help teens identify clear reasons why they think they need to continue using tobacco and why quitting may be better for them in the long run. It can be copied and used every one or two weeks to help teens see if their decisions about smoking have changed and if they want to talk someone about it.
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Write Before You Light
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This journal is designed to help the teen examine the relationship between his or her emotional health and tobacco use throughout the day. Teens can track projected smoking, actual smoking, associated mood, and possible environtal or social triggers that lead to craving tobacco. The journal can be easily duplicated and is accompanied by a brief set of instructions. |
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