<< Back to main link page Implementation Tools and Resources   This Tool Kit includes sample forms to assist with various tasks included in revising patient flow and documentation of care to implement the recommended 5 A's. Forms have been developed at several institutions and may be copied or modified for use by individuals who use the Smoking Cessation for Pregnancy and Beyond program. If the forms are widely distributed, please give appropriate credit to the developing institution. To contact us with questions regarding these forms or additional office system resources, e-mail: quitsmoking AT dartmouth DOT edu. In order to view these PDF Files, you must have Adobe Acrobat Reader installed -- Download it here. Office Systems Assessment Documents for Clinics Chart Audit Form Patient Path Analysis: Blank Form Patient Path Analysis: Sample Completed Form Tools to assess a pregnant woman's smoking status Smoking History Survey for Pregnant Women Recommended Questions to Assess Smoking Status Documentation of Smoking Cessation Counseling Pregnancy Smoking Cessation Flow Sheet Cessation Counseling Contact and Referral Form Sticker Samples - the number next to each link is the Avery Label Code -- you will need to use this type of label sheet to print each set of stickers. Flow Sheet Sticker (5097) Problem List Sticker (5261) Vital Sign Sticker (5097) Smoker/Non-Smoker Sticker (5293) Patient Education Materials Brochures and Booklets Quit Smoking Brochure Tear Sheet: Quit Smoking Tear Sheet: Quit Smoking During Pregnancy Free copies of the above brochures can be ordered by contacting the Agency for Healthcare Research and Quality, 800-358-9295, the Centers for Disease Control and Prevention, 800-CDC-1311, or the National Cancer Institute, 800-4-CANCER. ACOG Self Help Booklet For free single copy, email resources@acog.org, including your name, organization, and address. To order additional pamphlets, call 800-762-ACOG x882. American Cancer Society free brochures (listed below) are available by calling their toll-free number, 1-800-ACS-2345 (1-800-227-2345). Kicking Butts-Your Step-by-Step Guide to Quitting Smoking (Book: Code 9511.00) Living Smoke-free For You and Your Baby (Pamphlet: Code 2717.00) Set Yourself Free: A Smoker's Guide (Pamphlet: Code 2054.00) Posters "Pregnant and Smoking? (It's okay to ask for help.)" "Pregnant and Smoking? (It's okay to ask for help.)" -- designed for American Indian/Alaska Native audiences Free copies of the above posters can be ordered by contacting the National Partnership to Help Pregnant Smokers Quit via email at info@helppregnantsmokersquit.org or by calling 919-843-7663. "You Can Quit Smoking" Provided by the U.S. Department of Health and Human Services -- 800-358-9295 Quit Line Info Great Start Quitline Information (website) -- Free phone consultation program of American Legacy Foundation Quitline Brochure from the American Cancer Society Training & Handouts ACOG Smoking Cessation Training for Clinicians (Powerpoint) Printable Program Control Cards: a Useful Program Navigation Tool (Powerpoint)

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