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 ………………………………………………….


Microsoft word - kch-15-ck-erhöhung_0801.doc

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

Rizk abdel-moneim rizk

Maher Helmy Elsayed Helal Chemistry Dept., Faculty of Science, Helwan University, Cairo, Phone: (002)0225565548, Mobile: 0101154456, E-mail: ______________________________ Education .Ph.D., Organic Chemistry, Helwan Universit y 1990-1994 .M. Sc., , Organic Chemistry Helwan Universit y 1983-1990 .B. Sc., Chemistry, Elmnofia University 1982 _______________________

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