N.H. Admin. Code § Ph 2604.02

Current through Register No. 50, December 12, 2024

Section Ph 2604.02 - Forms

(a) The "NH Tobacco Cessation Self-Screening Patient Intake Form" shall contain the following:

(1) Name of the patient;

(2) Date of birth of the patient;

(3) Age of the patient;

(4) The date completed;

(5) Blood pressure and mmHg at the time the form is completed;

(6) Yes or no to the question "Do you have health insurance";

(7) Name of the insurance provider, PCP, or health care provider;

(8) List of medications being taken by the patient;

(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) Answer to the question "Do you have a preferred tobacco cessation product you would like to use";

(11) Yes or no to the question to "Have you tried quitting smoking in the past" and if yes describe the attempt;

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

a. Cold turkey;

b. Tapering or slowly reducing the number of cigarettes you smoke a day;

c. Medicine:

1. Nicotine replacement (like patches, gum, inhalers, lozenges, etc.); or

2. Prescription medications (ex. Bupropion [Zyban, Wellbutrin], Varenicline [Chantrix]

d. Other;

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

a. Are you under 18 years of age;

b. Are you pregnant, nursing, or planning on getting pregnant or nursing in the next 6 months; and

c. Are you currently using and trying to quit non-cigarette products (ex. Chewing tobacco, vaping, e-cigarettes, Juul);

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

a. Have you ever had a heart attack, irregular heart beat or angina, or chest pains in the past two weeks;

b. Do you have stomach ulcers;

c. Do you wear dentures or have TMJ (temporomandibular joint disease;

d. Do you have a chronic nasal disorder (ex. Nasal polyps, sinusitis, rhinitis);

e. Do you have a chronic nasal disorder (ex. Nasal polyps, sinusitis, rhinitis); and

f. Do you have asthma or another chronic lung disorder (ex. COPD, emphysema, chronic bronchitis;

g. Have you ever had an eating disorder such as anorexia or bulimia;

h. Have you ever had seizure, convulsion, significant head trauma, brain surgery, history of stroke, or diagnosis of epilepsy;

i. Have you ever been diagnosed with chronic kidney disease;

j. Have you ever been diagnosed with liver disease;

k. Have you been diagnosed with or treated for mental health illness in the past 2 ears (ex. Depression, anxiety, bipolar disorder, schizophrenia;

l. Do you take a monoamine oxidase inhibitor (MAOI) antidepressant (ex. Selegiline [Emsam, Zelapar], Phenelzine [Nardil], Isocarboxazid [Marplan], Tranylcypromine [Parnate], Rasagiline [Azilect]);

m. Do you take linexolid (Zyvox); and

n. Do you use alcohol or have you recently stopped taking sedatives (ex. Benzodiazepines);

(15) Yes or no to the question "Do you smoke fewer than 10 cigarettes a day";

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

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

1. Little interest or pleasure in doing things; and

2. Feeling down, depressed or hopeless;

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

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) The patient's signature and date of signing.

(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.

N.H. Admin. Code § Ph 2604.02

Derived from Number 10, Filed March 9, 2023, Proposed by #13559, Effective 4/12/2023, Expires 4/12/2033.