159 (159)    MH REPORT (601.93)

Name Value
REPORT NUMBER 159
INSTRUMENT HSI
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