First Peoples Wellness
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NRT Questionnaire
Nicotine dependence check-in and dosage estimates.
Example
Reset
Client Information
Name / ID
Birthdate
Medical #
First Nation status #
Date
Primary Use
Smoke + Vape
Smoke only
Vape only
Dependence Check-In
Adapted FTND-style wording.
How soon after waking?
Select...
Within 5 mins (3)
6-30 mins (2)
31-60 mins (1)
After 60 mins (0)
Hard to refrain in forbidden places?
Select...
Yes (1)
No (0)
Hardest to give up?
Select...
First one in morning (1)
Any other (0)
Cigarettes per day?
Select...
0 / None (0)
10 or less (0)
11–20 (1)
21–30 (2)
31+ (3)
More in first hours of waking?
Select...
Yes (1)
No (0)
Use even when sick in bed?
Select...
Yes (1)
No (0)
Nicotine Estimates
Cigarettes per day
Strength (mg/mL)
Volume (mL)
Unit
Days
Weeks
Duration
