Nicotine Assessment

FAGERSTROM TEST FOR NICOTINE DEPENDENCE
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Who is your provider?
Do you smoke cigarettes?*

YesNo
How soon after waking do you smoke your first cigarette?*

Within 5 minutes5-30 minutes31-60 minutes
Do you find it difficult to refrain from smoking in places where its forbidden? e.g. Church, Library, etc.*

YesNo
Which cigarette would you hate to give up?*

The first in the morningAny other
How many cigarettes a day to you smoke?*

10 or less11-2021-3031 or more
Do you smoke more frequently in the morning?*

YesNo
Do you smoke even if you are sick in bed most of the day?*

YesNo
Nicotine Dependence Score
Score:
1-2 = low dependence
3-4 = low to mod dependence
5-7 = moderate dependence
8+ = high dependence
Should be Empty:

FAGERSTROM TEST FOR NICOTINE DEPENDENCE