SMOKING CESSATION SCORING FORM
First Name:
Last Name:
Student ID:
Content Checklist
CC: I need some guidance in quitting smoking.
I believe I am ready to commit to quit
HPI: smoked for 6 years; started at age 18
1 pack a day since age 18
Smokes first cigarette after waking and last before bed
Parents quit smoking two months ago
Tried to stop on 2 occasions (cold turkey); only lasted for 3 days
Triggers: family related stress; school stress
Reasons for quitting: concerned about lungs and risk of lung cancer later in life given family history
Concerns about quitting: hard to give up habit; weight gain, fear of failure
PMH: Depression
Medications: self medicates with Vitamin D (200 IU.) as an anti-depressant
Allergies: none
FH: father diagnosed with lung cancer in 2007
SH: has no insurance and cannot afford healthcare; partially dependent on parents
Occupation: works as a medical technician part time
Alcohol: 2-3 beers once a week.
No other drug use.
Counseling Checklist
Student affirms the benefits of quitting and the costs of smoking
Student recommends: nicotine replacement and/or medication to help
Student suggests keeping a log of smoking behavior
Student helps you pick a quit date
Student suggests eliminating triggers: ash trays; car smell; places
Student asks about support for quitting
Student suggests new distractions, stress relievers
Student suggests a contract
Student suggests follow-up
MIRS
Opening
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Elicits Spectrum of Concerns
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Negotiates Priorities and Sets Agenda
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Eliciting the Narrative Thread or the "Patient's Story"
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Organization
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Pacing of Interview
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Types of Questions
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Summarizing
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Lack of Jargon
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Verbal Facilitation Skills
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Non-Verbal Facilitation Skills
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Empathy and Acknowledging Patient Cues
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Patient's Perspective (Beliefs)
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Support Systems
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Patient's Education and Understanding
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Assess Motivation for Changes
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Achieve a Shared Plan
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Encouragement of Questions
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Closure
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