Quit Smoking & Nicotine Dependence Patient Intake Form

Patient Details

Please provide your personal details. All fields marked with * are required.

1Name *

Please enter your first and last name

2Date of Birth *

Please select your date of birth

3Street Address *

Please enter your address

4Mobile Number *

Please enter a valid mobile number

5Email Address *

Please enter a valid email address

6Medicare Number *

Please enter a valid Medicare number

7Individual Reference Number (IRN) *

Please enter your IRN

8Medicare Expiry Date *

Please select the expiry month and year

Smoking & Nicotine History

We will now collect more detailed information to provide to the doctor.

9What is your current smoking status? *

I am currently smoking and would like to try nicotine vaping products.

I have quit smoking using vaping products and am managing a nicotine dependence.

I am currently using vaping products to manage a nicotine dependence.

I have never smoked or vaped before.

Please select your smoking status

10How many cigarettes do you smoke per day? *

None

Fewer than 5

5-10

11-20

20-40

40+

Please select an option

11How many years have you smoked in total? *

None

Fewer than 5

5-10

10-20

20-30

30+

Please select an option

12How many times have you attempted to quit? *

0 times

1-3 times

3-5 times

5+ times

Please select an option

13What quit methods have you tried previously? *

TGA guidelines state that patients must have tried to quit using first-line treatments to be eligible for a nicotine prescription.

NRT (Patch/Gum/Other)

Nicotine pouches

Cold Turkey / Willpower

Quitline / Counselling

Champix

Zyban

None

Please select at least one option

14What are your main reasons for quitting? *

Health

Cost

Family/friends

Work

Social reasons

Pregnancy planning

Please select at least one reason

15What are your key triggers? *

Stress

Alcohol

Coffee/Tea

Work breaks

Driving

Social situations

Boredom/habit

Please select at least one trigger

Medical History & Mental Health

We will now learn a bit more about your medical history and mental health.

16Do you have a history of any of the following conditions? *

Heart disease, chest pain (angina), or heart attack

Stroke or mini-stroke (TIA)

COPD

Asthma

Diabetes

Chronic kidney disease

Chronic liver disease

Seizure disorder/epilepsy

None

Please select at least one option

17Do you have any of the following conditions? *

Depression

Anxiety/panic

Bipolar disorder

Psychosis/schizophrenia

PTSD / trauma-related

None

Please select at least one option

18Known reaction to PG (propylene glycol)? *

Yes

Please select an option

19Known reaction to VG (vegetable glycerin)? *

Yes

Please select an option

20What are your current medications? (if any)

21Are you pregnant, breastfeeding, or planning pregnancy? *

Yes

Please select an option

22Do you have a history of substance use problems? *

Yes

Please select an option

Vaping History & Preferences

We will now learn a bit more about your vaping history (if any) and preferences.

23Do you currently use a vape? *

Yes

Please select an option

24What type of vape device do you currently use? *

Disposable vape

Pod system

Nicotine inhaler

I'm not sure / (none)

Please select an option

25Are you managing a nicotine dependence? *

Yes

I don't know

Please select an option

26What nicotine strength are you currently using? *

None (0mg)

Low (1–6 mg)

Medium (7–20 mg)

High (21–50 mg)

Unsure

Please select an option

27How often do you vape nicotine products? *

Never

Occasionally

A few times per day

Hourly

Constantly / very frequently

Please select an option

By submitting this form, you consent to your information being used for review by our doctors. Your data is handled in accordance with our Privacy Policy.

Thank you!

Your form has been successfully submitted. A doctor will review your details and contact you via email within 24 hours regarding your approval.

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