Smoking Cessation Intake Form

Smoking Cessation Intake Form — Form Fields

This healthcare template includes 6 fields. Gather baseline information from patients enrolling in a smoking cessation program. Captures smoking history, quit motivation, and previous cessation attempts. Helps counselors develop personalized quit plans. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Type of Tobacco Product Used (dropdown selection, required) — options: Cigarettes, Cigars, Chewing / smokeless tobacco, E-cigarettes / vaping, Pipe, Multiple products
• Years of Tobacco Use (number, required)
• Previous quit attempts (multiple choice, required) — options: None – this is my first attempt, 1–2 previous attempts, 3 or more previous attempts
• Motivation to quit (readiness stage) (multiple choice, required) — options: Ready to quit now, Thinking about quitting (within 6 months), Not ready – exploring options
• Reasons for Wanting to Quit (long text, optional)