CASE 3 - SMOKING CESSATION COUSELING SCORING FORM

First Name:
Last Name:
Student ID:

History Checklist
Patient in for recall prophylaxis, teeth stained, gums bleed	select answerYesNo
Changes to medical status explored	select answerYesNo
Asks if patient still smoking, how much, and type of tobacco	select answerYesNo
Advises patient to quit	select answerYesNo
Explains effects of smoking on general health	select answerYesNo
Explains effects of smoking on oral health	select answerYesNo
Explains effects of second hand smoke on children	select answerYesNo
Explains benefits of smoking cessation	select answerYesNo
Reviews pharmacotherapies for smoking cessation	select answerYesNo
Assesses patient?s readiness to quit	select answerYesNo
Explores barriers to quitting	select answerYesNo
Assesses support system for challenges during quit attempt	select answerYesNo
Creates a specific quit plan with quit date	select answerYesNo
Arranges follow up care for after the quit date	select answerYesNo

MIRS
Opening	select answer12345
Elicits Spectrum of Concerns	select answer12345
Negotiates Priorities and Sets Agenda	select answer12345
Eliciting the Narrative Thread or the "Patient's Story"	select answer12345
Timeline	select answer12345
Organization	select answer12345
Pacing of Interview	select answer12345
Types of Questions	select answer12345
Summarizing	select answer12345
Duplication	select answer12345
Lack of Jargon	select answer12345
Verbal Facilitation Skills	select answer12345
Non-Verbal Facilitation Skills	select answer12345
Empathy and Acknowledging Patient Cues	select answer12345
Patient's Perspective (Beliefs)	select answer12345
Support Systems	select answer12345
Patient's Education and Understanding	select answer12345
Assess Motivation for Changes	select answer12345
Encouragement of Questions	select answer12345
Closure	select answer12345