Stop Smoking Assessment

25/02/2024 02/12/2025

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at enquiries@thefamilychemist.co.uk

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

Yes No

2b. Who is this medication for? Please provide full name, date of birth and registered address of the patient.

3. Are you aged between 18 and 65?

You cannot use Cytisine. You may be eligible for other treatments.

Yes No

4. Are you breast feeding, pregnant or planning to become pregnant?

Yes No

4b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are

Medical History

5. Do you currently smoke?

STOP: You cannot use Stop Smoking Treatments if you do not smoke.

Yes No

6. Do you take any medication for, or have a history of any mental health condition?

Yes No

6b. Please provide more details: Do you still take medication and if so what medication do you take?

7. Do you have a history of epilepsy, seizures or have a low seizure threshold?

Yes No

7b. Please provide more details:

8. Have you tried Champix (Varencline)/ Zyban (bupropion)/Cytisine in the past to stop smoking?

Yes No

8b. When did you use Champix/ Zyban/ Cytisine? Did you ever experience side effects?

9. What is your blood pressure?

Low - Below 90/60

Normal - Between 90/60 and 140/90

High - Above 140/90

10. Do you drink alcohol?

Using Zyban with excessive alcohol may increase the risk of uncommon side effects. On the other hand, sudden withdrawal from alcohol following regular or chronic use can also increase your risk of seizures during treatment with buPROPion

Yes No

10b. Please enter what you drink and how much you drink in average over a week?

11. Do you have any dependency to benzodiazepines?

Yes No

11b. Please provide me more details

12. Do you suffer from or ever suffered from any of the following?

Central nervous system tumour.
Current or previous diagnosis of eating disorders like bulimia or anorexia nervosa.
Severe hepatic cirrhosis
History of bipolar disorder
History of head trauma
History of recent stroke or heart attack
Heart problems
Diabetes treated with tablets or insulin
Alcohol abuse
Use off stimulants or anorectic products
Unstable angina

Yes No

12b. Please provide more details:

Past Medical History

13. Do you have any kidney or liver impairment?

Yes No

13b. Please provide more details

14. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

14b. Please provide more details:

15. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

15b. Please provide more details:

16. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

16b. Please provide more details:

17. Would you like us to pass on details of your treatment to your GP?

Yes No

17b. Please provide more details:

Please Provide GP Email (preferred):

Unable to find your surgery? Click Here

18. Do you give consent for our clinical team to check your NHS Summary Care Records if required?

Yes

19. Do you agree with the following?

I have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
I will stop treatment of Champix/ Zyban / Cytisine if I develop changes in behaviour or thinking, anxiety, psychosis, mood swings, aggressive behaviour, or depression, or if I develop suicidal thoughts or behaviours, I will inform my doctor immediately.
I will stop treatment with Champix/Zyban / Cytisine if I experience a seizure while on treatment.
I will monitor my blood pressure regularly whilst taking Zyban. I will stop taking Zyban and seek medical attention if my blood pressure raises higher than 150/90.
I will notify my doctor if I develop new or worsening cardiovascular symptoms and to seek immediate medical attention if I experience signs and symptoms of a heart attack or stroke.
I have answered the questions honestly and accurately and the treatment is solely for my personal use.
I will read and understand the patient information leaflet supplied with my medication.
I understand that although it is not compulsory it is important to inform my GP of this treatment so they can provide safe healthcare.
I understand prescribing decisions will be based on the answers from my consultation and incorrect information can cause harm to my health. Orders may be rejected if not clinically suitable.
I am aware that The Family Chemist will undertake a soft check to validate my identity using LexisNexis. Note: This does not affect your credit rating.
I have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes

20. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Stop Smoking Assessment

About You

Medical History

Past Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

Opening times

Today’s Responsible Pharmacist

About You

Medical History

Past Medical History

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