| RPT |
|.|.|Heaviness of Smoking Index (HSI) |
|1-2 = Low dependence
|3-4 = Moderate dependence
|5-6 = High dependence| |
<*Answer_7772*>|
<*Answer_7773*>|
<*Answer_7774*>|
|(Question and Answers)|
1. How soon after you wake up do you smoke/use your first
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
cigarette/chew?|<*Answer_7875*>| |
2. How many cigarettes do you smoke in a day?|<*Answer_7876*>| |
Adapted with permission: The Fagerstrom Test for Nicotine Dependence: a
revision of the Fagerstrom Tolerance Questionnaire, by T. F. Heatherton,
L. et al., 1991 British Journal of Addiction, 86(9).| |
Heatherton, T. F., et al. (1989). Measuring the heaviness of smoking:
Using self-reported time to the first cigarette of the day and number of
cigarettes smoked per day. Addiction, 84, 791-800.| |
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic activities. $~
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
| Gender: <.Patient_Gender.>|
|<*Answer_7771*> | |
|RANGE OF SCORES
|0 = No dependence
|
