Questions Related to Quit Smoking

In order to prescribe treatments for Quit smoking our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

How long have you been a smoker?

Why do you want to quit smoking?

Have you tried to quit smoking before, if so how?

Yes No

Could there be any chance that you may be pregnant?

Yes No

Are you currently breastfeeding?

Yes No

Do you have epilepsy?

Yes No

Do you have history of any psychiatric illness including depression?

Yes No

How many do you smoke a day?

Are you taking insulin, warfarin, theophylline?

Yes No

Do you suffer from sever renal impairment (kidney problems) or do you get dialysis?

Yes No

Are you currently taking, doing or using anything to help you stop smoking?

Yes No

Please confirm that you are aware that treatment with Champix should be stopped if agitation, depressed mood or changes in behaviour are causing concern

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