TalkToYourPatients.ny.gov

Ask

Ask every patient at every visit "Do you smoke?" Document tobacco use status along with vital signs. Expanding the vital signs to include tobacco use status, or the use of other reminder systems such as chart stickers or computer prompts, significantly increases clinical intervention. Below are two samples.

PATIENT CHART OPTIONS

Vital Signs
Date: ___________________ Temp: ___________________
BP: ___________________ Pulse:___________________
Height: ___________________ Weight:______ BMI: _______
     
  Yes No
Tobacco Use: _____ _____
Advice Given: _____ _____
Ready to Quit: _____ _____
Referral Made: _____ _____
Rx Given: _____ _____
     
Vital Signs
Date: ___________________ Temp: ___________________
BP: ___________________ Pulse: ___________________
Height: ___________________ Weight:______ BMI:______
     
  Yes No
Tobacco Use: _____ _____
Advice Given: _____ _____
Ready to Quit: _____ _____
Referral Made: _____ _____
Rx Given: _____ _____
     
0 1 2 3 4 5 6 7 8 9 10
No Pain   Mild   Moderate   Severe   Very Severe   Worst Pain