BRIEF TOBACCO INTERVENTION REGISTRY

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Contact Referr
No. ed for
Pharm
Intensi
NAME Sex Complete Address Comorbidities Tobacco (Nicotine) Use acothe
(Mobile/ ve
rapy
Landline Couns
Brief Tobacco Intervention
number) Follow up eling
(BTI) provided

Non-
Tobac
9a 9b 9c 9d 9e 9f Current Tobacco User
co
Date of Date of Age
Use
Assessmen Birth
Remar
No. Philhealth No. t In
11b ks
(mm/dd/y (mm/dd/
yyy) yyyy) Years 10a 10b 10c 10d 10e 12a 12b
Pregnan Ready to quit
Last First 11a
M.I. M F t within 30 days Y/N Y/N
Name Name
(Y/N)
Not
ASTH OTHER No. Nicotine
HPN DM COPD TB Expos ready
MA S of Dependence 30
ure to No. of to quit Quit 24h
Sticks No. of Score days
Tobac Year/s date Quit post-
consu Pack- post-
co Smokin (mm/ Plan quit
me Year/s <4 ≥4 quit
Smok g dd/yy) date
per/ date
e Y/N
day

10

11

12

13

14

15

16

17

18

19

20

TOT M: F: P: Total: Total: Total: Total: Tot Total: Total: Tota Total: Total: A= Total: Total:
AL ____ ____ ____ ____ al: ____ ____ l: ____ ____ ____ ____
___ ___ R=
 BRIEF TOBACCO INTERVENTION REGISTRY
_ _ L=

No. of clients with co-morbidity:

LEGEND:
● Provide materials on ill effects of exposure to secondhand and third hand tobacco smoke
● Provide self-help materials for quitting tobacco (nicotine) use
● No. of packs years = no. of sticks / 20 x no. of years smoking (Column 10b/20 x 10c)