Microsoft word - smoking cessation.docx
Name________________________ Age_________ Date of Birth__________ Today’s Date___________
Primary Care Physician’s Name_____________________
Date of Last Physical Exam_______________ Allergies_________________
Smoking History________ pack(s)/day for _______ years Previous Smoking Cessation Methods Attempted (circle below)
Chantix Zyban Gum Nicoderm Inhaler Hypnosis Willpower
Alcohol Usage: YES/NO Amount__________ Drug Use: YES/NO
Your Past Medical History (Please circle below)
Past Family History (Please circle below)
List of Current Medications___________________________________________________________________________________
Review of Current Symptoms (Please Circle as appropriate)
Smoking Cessation Tips
Prior to Stopping
Decide you’re going to stop and set a target date.
Make a list of 10 reasons why you want to stop.
Post the list everywhere. The mirror, the bedroom door, at
Before the first treatment get your teeth cleaned,
and appreciate how good they look. Don’t let smoking discolor
Change your environment. Get rid of all cigarettes and ashtrays
in your home, car and the workplace before the
first treatment. Don’t carry cigarettes with you. Freshen the air. Clean your clothes.
Enroll the assistance of family and friends.
If your spouse smokes encourage them to stop too.
On the first day do something to celebrate.
Try to avoid situations and places in which you would normally smoke.
Also try to lower your stress level. Do
go to places where smoking is prohibited such as movie theatres, church, etc.
Cravings last only about 2 minutes.
During the craving find something to do with with your mouth and hands,
such as eating a hard candy, bite on a toothpick, pretzel stick, etc.
Sip water throughout the day.
For withdrawal headaches use acupressure or take Tylenol.
Use relaxation breathing, the 3/4/5 technique. Breath for 3 seconds, hold for 4 seconds, exhale for 5 seconds.
This helps you relax.
Most withdrawal symptoms pass in 1-2 weeks.
Keep busy your hands busy with crossword puzzles, writing
Place a mark on your calendar
for each day you’re a none smoker. Put the money you’ve saved aside and
with something special.
If you smoke again, realize many people slip and your on the path to becoming a non-smoker. Try to lean
what the trigger was? And how you’ll cope with it in the future? Come back for another treatment.
Remaining a Non-smoker
Write down a list of reasons you’re glad you stopped. Post it everywhere.
Don’t buy additional cigarettes. Continue to reward yourself with the money you’ve saved.
in which you commonly smoke. If you can’t try to visualize in advance how you’ll handle
certain situations, then follow through.
Auricular Therapy for Smoking Cessation
What it Involves
A small electrical probe is placed at precise points on your outer ear. The points are then stimulated for up to 24 seconds at each point. No needles are involved. The total treatment time is about 10 minutes and both ears are treated.
What you may experience during or after a treatment.
Reactions vary from an intense feeling of pleasure, tingling, or warmth over the body, to breaking out in a sweat, or a facial blush, to feeling nothing at all.
A sense of pressure on the ear at the point of stimulation.
You may be asked to wear a small magnet on certain acupuncture points on your outer ear. You then stimulate these several times throughout the day. This tends to prolong the effect of the treatment.
Side Effects of the Treatment
Most commonly patients experience a transient warmth, redness and slight tenderness on the outer ear. This lasts about 24 hours.
Less commonly patients describe ringing in the ears during the treatment and the onset of a migrane headache in those with a history of migranes.
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