1. (a) The “NH Tobacco Cessation Self-Screening Patient Intake Form” shall contain the following:

   1. (1) Name of the patient;
   2. (2) Date of birth of the patient;
   3. (3) Age of the patient;
   4. (4) The date completed;
   5. (5) Blood pressure and mmHg at the time the form is completed;
   6. (6) Yes or no to the question “Do you have health insurance”;
   7. (7) Name of the insurance provider, PCP, or health care provider;
   8. (8) List of medications being taken by the patient;
   9. (9) Yes or no to “Do you have any allergies to medication” and if yes list the medication the patient is allergic to including any food allergies;
   10. (10) Answer to the question “Do you have a preferred tobacco cessation product you would like to use”;
   11. (11) Yes or no to the question to “Have you tried quitting smoking in the past” and if yes describe the attempt;

   12. (12) Answer the question “What best describes how you have tried to stop smoking in the past” with one of the following:

       1. a. Cold turkey;
       2. b. Tapering or slowly reducing the number of cigarettes you smoke a day;

       3. c. Medicine:

          1. 1. Nicotine replacement (like patches, gum, inhalers, lozenges, etc.); or
          2. 2. Prescription medications (ex. Bupropion [Zyban, Wellbutrin], Varenicline [Chantrix]_
       4. d. Other;

   13. (13) Answer yes, no, or not sure to the following background information questions:

       1. a. Are you under 18 years of age;
       2. b. Are you pregnant, nursing, or planning on getting pregnant or nursing in the next 6 months; and
       3. c. Are you currently using and trying to quit non-cigarette products (ex. Chewing tobacco, vaping, e-cigarettes, Juul);

   14. (14) Answer yes, no, or not sure to the following medical history questions:

       1. a. Have you ever had a heart attack, irregular heart beat or angina, or chest pains in the past two weeks;
       2. b. Do you have stomach ulcers;
       3. c. Do you wear dentures or have TMJ (temporomandibular joint disease;
       4. d. Do you have a chronic nasal disorder (ex. Nasal polyps, sinusitis, rhinitis);
       5. e. Do you have a chronic nasal disorder (ex. Nasal polyps, sinusitis, rhinitis); and
       6. f. Do you have asthma or another chronic lung disorder (ex. COPD, emphysema, chronic bronchitis;
       7. g. Have you ever had an eating disorder such as anorexia or bulimia;
       8. h. Have you ever had seizure, convulsion, significant head trauma, brain surgery, history of stroke , or diagnosis of epilepsy;
       9. i. Have you ever been diagnosed with chronic kidney disease;
       10. j. Have you ever been diagnosed with liver disease;
       11. k. Have you been diagnosed with or treated for mental health illness in the past 2 ears (ex. Depression, anxiety, bipolar disorder, schizophrenia;
       12. l. Do you take a monoamine oxidase inhibitor (MAOI) antidepressant (ex. Selegiline [Emsam, Zelapar], Phenelzine [Nardil], Isocarboxazid [Marplan], Tranylcypromine [Parnate], Rasagiline [Azilect]);
       13. m. Do you take linexolid (Zyvox); and
       14. n. Do you use alcohol or have you recently stopped taking sedatives (ex. Benzodiazepines);
   15. (15) Yes or no to the question “Do you smoke fewer than 10 cigarettes a day”;

   16. (16) Answer the following questions with not at all, several days, more than half the days, or nearly every day:

       1. a. Over the last 2 weeks, how often have you been bothered by any of the following problems:

          1. 1. Little interest or pleasure in doing things; and
          2. 2. Feeling down, depressed or hopeless;

   17. (17) Answer the following suicide screening question with not at all, several days, more than half the days, or nearly every day:

       1. a. Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or thoughts of hurting yourself in some way; and
   18. (18) The patient’s signature and date of signing.
2. (b) The “Tobacco Cessation Assessment & Treatment Care Pathway” shall be the document revised 12/2022 and available on the boards web site, https://www.oplc.nh.gov/board-pharmacy-forms-and-documents.

Source. #13559, eff 4-12-23