NRT Questionnaire

Nicotine dependence check-in and dosage estimates.

Client Information

Name / ID

Birthdate

Medical #

First Nation status #

Date

Primary Use

Dependence Check-In

Adapted FTND-style wording.

How soon after waking?

Hard to refrain in forbidden places?

Hardest to give up?

Cigarettes per day?

More in first hours of waking?

Use even when sick in bed?

Nicotine Estimates

Cigarettes per day

Strength (mg/mL)

Volume (mL)

Unit

Duration

This tool supports reflection and conversation — it is not a diagnosis. If your results worry you, share them with a health care provider or someone you trust.
Cet outil soutient la réflexion et la discussion — ce n’est pas un diagnostic. Si vos résultats vous inquiètent, partagez-les avec un professionnel de la santé ou une personne de confiance.