| RPT |
|.|.|Fagerstrm Test for Nicotine Dependence (FTND) |
0-2 = Very low dependence|
3-4 = Low dependence|
5 = Medium dependence|
6-7 = High dependence|
8-10 = Very high dependence| |
Questions and Answers| |
1. How soon after you wake up do you smoke/use your first cigarette/chew?|
<*Answer_7951*>| |
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
2. Do you smoke/chew more frequently in the hours after waking than
during the| rest of the day?|
<*Answer_7952*>| |
3. Do you find it difficult not to smoke/chew?|
<*Answer_7953*>| |
4. Which cigarette/chew would be the hardest to give up?|
<*Answer_7954*>| |
5. How many cigarettes do you smoke in a day?|
<*Answer_7955*>| |
6. Do you smoke when you're so sick that you're home in bed?|
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
<*Answer_7956*>| |
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.| |
Adapted with permission: The Fagerstrm Test for Nicotine Dependence: a|
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
revision of the Fagerstrm Tolerance Questionnaire, by T. F. Heatherton,|
L. et al., 1991, British Journal of Addiction, 86(9).|
$~
| Gender: <.Patient_Gender.>| |
NICOTINE DEPENDENCE SCORE: <*Answer_7771*>| |
RANGE OF SCORES|
|
