Mr/mrs/miss/ms first name __________________________ surname _______________________________________
Mr/Mrs/Miss/Ms First Name __________________________ Surname _______________________________________ Today’s Date ________________ Date of Birth __________________ Age _____________________________________ Address __________________________________________________________________________________________ e-mail address
Home tel _____________________ Mobile ______________________ Work ________________________________ No. of dependent children ________ Occupation __________________ GP ____________________________ Questions about your smoking How recently has your GP advised you to stop smoking? In the last year / More than a year ago / Never Did your GP suggest you contacted Quitline on this occasion? Yes / No What is your main reason for wanting to stop now? To save money / Protect my health / To please others / How many cigarettes do you usually smoke each day?
What type of cigarette do you usually smoke? Ultra lights / lights / standard / roll ups / cigars Do you regularly use cannabis or legal highs? No / Yes With tobacco / Yes but not with tobacco How old were you when you first started smoking regularly ?
How soon after waking do you usually smoke? Within 5mins / 6-15mins / 16-30mins / after 1 hour Does your partner or anyone you live with smoke? No / Live alone / Yes Partner / Yes someone else How often do you wake up in the night and smoke? Never / Rarely / 1-2 times a week / Most nights Do you find it difficult not to smoke in non-smoking areas? Yes / No
Do you smoke more in the first few hours of the day? Yes / No Do you smoke if you are so ill you are in bed for most of the day? Yes / No How many times have you tried to stop in the last 5 years? Never / Once / 2-3 times / 4-5 times / over 5 times What is the longest time you’ve succeeded in stopping for? Hours / days / weeks / 1-3 months / over 3 months Which of these have you tried to help you stop? Nicotine Replacement Therapy, please specify type __________ Zyban / Champix / Any other method eg hypnotherapy, please specify ______________________ Have you had any side effects from a) Zyban Yes / No b) Champix Yes / No c) NRT Yes / No What was the main thing that led you back to smoking last time? Got too miserable / Craved too much / Put on weight / Got bad tempered / Got too stressed / Thought I could stop again easily / Cannabis smoking / Getting drunk / Something else On a scale of 1-10 (1 least determined/confident and 10 very determined/confident)
How determined are you to stop for good in the next few weeks? How confident are you of succeeding? 1 2 3 4 5 6 7 8 9 10 How did you hear about Quitline? Doctor / nurse / friend or family / radio / newspaper / poster or leaflet / other Have you been to Quitline before? Yes / No - If yes how long ago _______________ Are you a permanent Guernsey resident?
Questions about your health
How many times have you been to your GP about your health in the last year? Not at all / 1 or 2 times / 3 or 4 times / 5 -10 times / more than 10 times. In a typical WEEK how many alcoholic units (small glass of wine / half beer / single spirit) do you usually drink? None / 1-10 / 11-20 / 21-30 / 31-40 / 41-50 / more than 50 If you are female, are you Pregnant / Trying to conceive / Breast feeding / None of these Have you ever suffered from these illnesses? Are you still being treated ?
(circle one) Name of any medicines you are STILL taking
Any other current illness not listed above?
Any other medicines / tablets / injections not listed above?
Are you due for surgery? Yes / No If yes please give details Have you had recent surgery? Yes / No If yes please give details
All information collected is confidential and will be stored in accordance with Data Protection. I am aware I will be contacted by Quitline following my quit attempt to record progress. I understand and agree that the data may be passed on to my Doctor. Signed _____________________________________ Date _____________________
To be completed by Stop Smoking Specialist
Cessation method Quit date ____________________________________ Coppm ______________________________ Client seen : Group Drop In 1 to 1 Home visit Hospital inpatient Any further information NRT products given ……………………………………………. Received by ………………………………………………. Staff signature ………………………………………………….
Laborinformation / Klin. Chemie 15 01/2008 Sinnvolle Labordiagnostik bei CK-Erhöhung Eine Erhöhung der Creatinkinase (CK) wird häufig unerwartet im Rahmen einer routinemäßigenBlutentnahme festgestellt. In Abhängigkeit von der Anamnese und dem klinischen Befund führtdies zu den Fragen: Wie ist die Erhöhung bei dem klinisch gesund erscheinenden Patienten zubewerten? Ist sie Folge des bek