New Hampshire Code of Administrative Rules
Ph - N.H. Pharmacy Board
Chapter Ph 2600 - PHARMACIST INITIATION AND DISPENSING OF NICOTINE CESSATION THERAPY
Part Ph 2604 - PHARMACIST RECORD KEEPING PROCEDURES
Section Ph 2604.02 - Forms

Universal Citation: NH Admin Rules Ph 2604.02

Current through Register No. 52, December 26, 2024

(a) The "NH Tobacco Cessation Self-Screening Patient Intake Form" shall contain the following:

(1) Name of the patient;

(2) Date of birth of the patient;

(3) Age of the patient;

(4) The date completed;

(5) Blood pressure and mmHg at the time the form is completed;

(6) Yes or no to the question "Do you have health insurance";

(7) Name of the insurance provider, PCP, or health care provider;

(8) List of medications being taken by the patient;

(9) Yes or no to "Do you have any allergies to medication" and if yes list the medication the patient is allergic to including any food allergies;

(10) Answer to the question "Do you have a preferred tobacco cessation product you would like to use";

(11) Yes or no to the question to "Have you tried quitting smoking in the past" and if yes describe the attempt;

(12) Answer the question "What best describes how you have tried to stop smoking in the past" with one of the following:
a. Cold turkey;

b. Tapering or slowly reducing the number of cigarettes you smoke a day;

c. Medicine:
1. Nicotine replacement (like patches, gum, inhalers, lozenges, etc.); or

2. Prescription medications (ex. Bupropion [Zyban, Wellbutrin], Varenicline [Chantrix]

d. Other;

(13) Answer yes, no, or not sure to the following background information questions:
a. Are you under 18 years of age;

b. Are you pregnant, nursing, or planning on getting pregnant or nursing in the next 6 months; and

c. Are you currently using and trying to quit non-cigarette products (ex. Chewing tobacco, vaping, e-cigarettes, Juul);

(14) Answer yes, no, or not sure to the following medical history questions:
a. Have you ever had a heart attack, irregular heart beat or angina, or chest pains in the past two weeks;

b. Do you have stomach ulcers;

c. Do you wear dentures or have TMJ (temporomandibular joint disease;

d. Do you have a chronic nasal disorder (ex. Nasal polyps, sinusitis, rhinitis);

e. Do you have a chronic nasal disorder (ex. Nasal polyps, sinusitis, rhinitis); and

f. Do you have asthma or another chronic lung disorder (ex. COPD, emphysema, chronic bronchitis;

g. Have you ever had an eating disorder such as anorexia or bulimia;

h. Have you ever had seizure, convulsion, significant head trauma, brain surgery, history of stroke, or diagnosis of epilepsy;

i. Have you ever been diagnosed with chronic kidney disease;

j. Have you ever been diagnosed with liver disease;

k. Have you been diagnosed with or treated for mental health illness in the past 2 ears (ex. Depression, anxiety, bipolar disorder, schizophrenia;

l. Do you take a monoamine oxidase inhibitor (MAOI) antidepressant (ex. Selegiline [Emsam, Zelapar], Phenelzine [Nardil], Isocarboxazid [Marplan], Tranylcypromine [Parnate], Rasagiline [Azilect]);

m. Do you take linexolid (Zyvox); and

n. Do you use alcohol or have you recently stopped taking sedatives (ex. Benzodiazepines);

(15) Yes or no to the question "Do you smoke fewer than 10 cigarettes a day";

(16) Answer the following questions with not at all, several days, more than half the days, or nearly every day:
a. Over the last 2 weeks, how often have you been bothered by any of the following problems:
1. Little interest or pleasure in doing things; and

2. Feeling down, depressed or hopeless;

(17) Answer the following suicide screening question with not at all, several days, more than half the days, or nearly every day:
a. Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or thoughts of hurting yourself in some way; and

(18) The patient's signature and date of signing.

(b) The "Tobacco Cessation Assessment & Treatment Care Pathway" shall be the document revised 12/2022 and available on the boards web site, https://www.oplc.nh.gov/board-pharmacy-forms-and-documents.

Disclaimer: These regulations may not be the most recent version. New Hampshire may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.