HPE region smoking cessation referral form If you have any questions about our Smoking Cessation Referral Form, please email quit@southeastph.ca. Question Title * Has your patient used any form of tobacco in the past 7 days? (Required.) Yes No Question Title * Has your patient used any form of tobacco in the past 6 months? (Required.) Yes No Question Title * Do any of the following apply to your patient? Please select all that apply. Pregnant Breastfeeding Under 18 years of age None apply 1. AskPlease ask your patient the following questions Question Title * What form(s) of tobacco do you currently use? (Select all that apply.) Cigarette Pipe Cigar Smokeless tobacco E-cigarette Other (please specify) Question Title * How often do you smoke? Daily: Monthly: Question Title * How soon after waking do you have your first cigarette? Within 5 minutes Within 30 minutes Within 60 minutes 2. AdviseAs your health care provider, I strongly advise you to quit or reduce your smoking, as it is the most important thing you can do for your health, and I can help you. There are many ways we can help, including reducing your smoking or helping you to quit completely. 3. AssistPlease contact Public Health for more information at 613-966-5500 or 1-800-267-2803, ext. 600 or email ttl@hpeph.ca. Question Title * Assist checklist Discuss external support through Public Health Quit Smoking Clinic Provide patient with Public Health contact information Provide patient with Nicotine Replacement Therapy Starter Kit 4. Arrange - Follow up programPlease contact Public Health for more information at 613-966-5500 or 1-800-267-2803, ext. 600 or email ttl@hpeph.ca. Question Title * Patient name (Required.) Question Title * Best contact number for patient (Required.) Question Title * Requested contact time (Required.) 7AM - 9AM 9 AM - 12PM 1PM - 5PM No preference Question Title * Referring health care provider name (Required.) Question Title * Referring health care provider business address (Required.) Question Title * Referring health care provider contact number (Required.) Collection of personal health information: Personal health information collected on this form (e.g., tobacco and vaping product use and frequency) is kept confidential and used to monitor local data, plan and provide local programs and services, case management, program administration, and program evaluation. You may withdraw your consent to provide additional health information at any time. Any questions about the collection and use of this information or for more information about our privacy practices, contact our Privacy Officer, at privacy.officer@southeastph.ca or call 1-800-660-5853. Please see our Privacy Statement for more information. Question Title * Do your patient verbally consent to the above? Yes No Done
