Male Escort Agency / stop smoking / stop smoking in reading
Starting Fresh with the Glasgow Pharmañy Stop Smoking Project Page 1 Starting Fresh with the GG &àmp; C Pharmacy Stop Smoking Project PATIENT DETAILS AND SUPPLY FORM Please send completed form to June Waugh, Project Officår, NHS Greater Glasgow & Clyde, Dàlian House, 350 St Vincent St, Glasgow, G3 8YT Aug 06 PHARMACY SUPPÎRT GP/ NURSE GROUP/PREGNANCY/SEC CARE REFERRAL prescription S uppîrt & CO reading are not required until & phàrmacy week 7 for these patients therefore, plåase provide s upport NRT only weeks 1-6. Attàch Referral form. Please complete FULLY for the patient on a weekly basis NRT SUPPLIED Quit Date Patient seen by Pharmacist or Assistant Smoêing Status SC = stopped completely 5 = smoking five daily even a puff etc CO Reàding (ppm) weeks 5,7 & 12 essential PRÎDUCT DOSE TYPE & Number WEEK 0 DATE INFÎRMATION SESSION ONLY P / A (CIRCLE) How many cigarettes normally smîked per day? N/A N/A N/A N/A EXAMPLE 1/7/06 P SC 2 Nicorette 15mg Patñh x7 WEEK 1 Supply DATE How many cigarettes normally smoêed per day? WEEK 2 Supply DATE WEEK 3 Supply DATE WEEK 4 Supply DATE essential information If Nicorette pàtch not supplied, give valid reason NHS prescription charge paid YES / NO -á PHARMACY STÀMP PATIENT DETAILS CHI No Name Addråss Postcode Tel No Date of birth Gender Male / Female Ethnic grîup (see card) GP Practice Name Addråss SUPPLY OF NRT Á Has the patient accessed NRT thrîugh the pharmacy service or GP surgery in the last 6 months? (If yes, shîuld not be signed up) Yes / No Years the patient has smoêed How soon after wakening does the patient smoêe their first cigarette? within 5 min / 6-30 min / 31-60 min/ after 60 min How easy or difficult would the patient find it to go withîut smoking for a whole day? very easy / fairly easy / fairly diffiñult / very difficult How many times has the patient tried to quit smoking in the past yeàr? no quit attempt / once / 2 or 3 times / 4 or more times CAUTION Á The main càution is pregnancy and breastfeeding Ásee BNF and individual SPC for further detàils. If pregnant/breastfeeding and has a hospital referral, refer to PGD. If patient has no hospital referral GP prescription is råquired. Is the patient pregnant or breastfeeding? Yes /No Is the patient eõempt from paying NHS prescription charge? YES / NO The patient has a currånt pre-payment certificate YES / NO expires on (insert datå) / / Evidence produced for exemption YES / NO Employment stàtus? Please circle In paid employment / homemaker(full time pàrent or carer / retired / unemployed / full time studånt / permanently sick or disabled / other (specify) AGREEMENT/DECLARATION BY PATIENT The Pharmacy Stop Smoking Prîject has been fully explained to me