<p> 5 A’s Tobacco Cessation Counseling </p><p>Providers are encouraged to refer clients to the Oklahoma Tobacco Helpline at: 1-800-QUIT NOW (1-800-784-8669)</p><p>Visit Date ____/____/______/____/______/____/______/____/____ Start Time ____:______:______:______:____ Ask every client _ Does not smoke _ Does not smoke _ Does not smoke _ Does not smoke every time _ Recently quit _ Recently quit _ Recently quit _ Recently quit (1 minute) _ less than 25 _ less than 25 _ less than 25 _ less than 25 cigarettes cigarettes per day cigarettes per day cigarettes per day per day _25+ cigarettes per _ 25+ cigarettes per _ 25+ cigarettes per _ 25+ cigarettes per day day day day Advise all tobacco _ Benefits of quitting _ Benefits of quitting _ Benefits of quitting _ Benefits of quitting users of the _ Harms of continuing _ Harms of _ Harms of continuing _ Harms of continuing consequences (1 _ Personalized continuing _ Personalized message _ Personalized message to minute) message to quit _ Personalized to quit quit _ Recognize difficulty message to quit _ Recognize difficulty of _ Recognize difficulty of of quitting _ Recognize difficulty quitting quitting of quitting Assess willingness Readiness to quit in Readiness to quit in Readiness to quit in Readiness to quit in next to make a quit next 30 days: next 30 days: next 30 days: 30 days: attempt (1 minute) __ Yes __ Yes __ Yes __ Yes __ No __ No __ No __ No Reason for not Reason for not Reason for not quitting: Reason for not quitting: quitting: quitting: ______Assist with Set Quit Date: Set Quit Date: Set Quit Date: Set Quit Date: treatment and ____/____/______/____/______/____/______/____/____ referrals (3+ _ Problem-solving _ Problem-solving _ Problem-solving _ Problem-solving minutes) _ Provide materials _ Provide materials _ Provide materials _ Provide materials _ Identify Support _ Identify Support _ Identify Support _ Identify Support _ Refer to 1 800 QUIT _ Refer to 1 800 QUIT _ Refer to 1 800 QUIT _ Refer to 1 800 QUIT NOW NOW NOW NOW _ Pharmacotherapy _ Pharmacotherapy _ Pharmacotherapy _ Pharmacotherapy Arrange follow up _ Assess smoking _ Assess smoking _ Assess smoking status _ Assess smoking status at (1 minute) status at every visit status at every visit at every visit every visit _ Ask client about the _ Ask client about the _ Ask client about the _ Ask client about the quitting process quitting process quitting process quitting process _ Reinforce the steps _ Reinforce the steps _ Reinforce the steps _ Reinforce the steps the the client is taking to the client is taking to the client is taking to client is taking to quit quit quit quit _ Provide encouragement _ Provide _ Provide _ Provide _ Set follow up encouragement encouragement encouragement appointment _ Set follow up _ Set follow up _ Set follow up appointment appointment appointment Comments</p><p>End Time ____:______:______:______:____ Provider Signature Credentials</p>