Tobacco Control Programme Management System Page 1 of 2

User Name : Riyadh FC

(Alamal for mental health)
User Type : Clinic

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Personal Information :
National ID * Clinic * 763 : Riyadh FC (Alamal MH)  Gender * Male
First Name * Middle Name * Family Name *
Age * Select Here  Region * Riyadh  Email
Marital Status * Select Here  No of Children (If married) * Education * Select Here
Monthly Income * Select Here  Occupation * Select Here  Mobile No *
How to know clinic * Select Here 
Smoking Data :
Age of start smoking * Any smoker at home Yes No
Reasons of Beginning of Smoking

Reason Select Here 

Tobacco Forms * Select Here  How many times *  Cost per month

Type How many times Cost per month

Nicotine Dependence Score :

Smoking Period > 15 Years Yes No No of Pack per day Risk Status :

How soon after waking do you smoke first cigarette ? 5-30 31-60
With in 5 minutes
minutes minutes
Do you find it difficult to refrain from smoking in places where it is forbidden ? e.g. Church,
Library etc. Yes No

Which cigarette would you hate to give up ? The first in the

Any other None
morning

How many cigarette a day do you smoke ? 10 or less 11-20 21-30

more
Do you smoke more frequently in morning ? Yes No
Do you smoke even if you are sick in bed most of the day ? Yes No
Fagerstrom score Fagerstrom Result
Examination :
Height(cm) Weight(kg) BMI
BP Sys BP DIS Co
Past Medical History :
C.V.S H.T.N I.H.D Arrhythmias
C.N.S Epilepsy Stroke Head trauma
Psychiatric Depression Schizophrenia Bipolar
Dermatology Eczema Psoriasis Skin allergy
Hypercholesterolemia D.M
Respiratory B.A COPD
G.I.T.S Peptic ulcer GORD Mouth Ulcer
Reproductive Erectile dysfunction Menopause Infertility
Malignancy
Renal CKD Stones UTI
Other Drugs Abuse Current Medication Allergy hx. Infectious disease
Quitting Trials :
Previous Quit Attempts Yes No No of Attempts Longest Quit Period Most recent attempt
Method Used
Reason for Relapse
Without Support Counseling Only NRT Patch NRT Lozenge Varencline

Reasons of un willing
Reason Select Here 
Reasons of Quitting

https://webbi.moh.gov.sa/war/Ehealth.html 10/3/2019
Tobacco Control Programme Management System Page 2 of 2

Reason Select Here 

Diagnosis Notes

Other Speciality Psychologist Remarks

Management :
Follow up
Add Visit Date Treatment Results Recommendation
date
Notes

Quit line center :

Add Date of calling Results Recommendation Notes Refusal Physician Name

Pharmacological treatment for Tobacco Dependence(Dosage and methods) :

Nicotine Patch
:- <10 cigarettes/day: 14 mg patch,replace patch every 24 hour, rotate application site.
:- >10 cigarettes/day: 21 mg patch,replace patch every 24 hour, rotate application site.
Nicotine Lozenge
:- First cigarettes>30 minutes after walking: 1 lozenge every 1-2 hours while awake, patient should use like a cough drop, do not chew a swallow
:- First cigarettes<30 minutes after walking: 1 lozenge every 1-2 hours while awake, patient should use like a cough drop, do not chew a swallow
Bupropion SR tablets
:- 150 mg QD for 3 days, then 150 mg BID
Varenicline tablets
:- 0.5 mg QD for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID.
For more information, please refer to SAUDI GUIDULINE

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https://webbi.moh.gov.sa/war/Ehealth.html 10/3/2019