The Market Cross Surgery
The Market Place
Corby Glen
Lincs NG33 4NH
Telephone 01476 550056
Fax 01476 552909
Spending time thinking about the questions below and filling in your answers will help you to plan a positive approach to stopping smoking. Please be honest with your answers which will enable us to be of assistance to you. Why do I want to stop? What is the major benefit to me? Do I enjoy smoking? When will I stop? Plan a date within 2 weeks after your first appointment at the Surgery. The day I stop, what will I do to prepare? Am I prepared to stop, not cut down? SMOKING HISTORY
Cigars If a pipe or roll-ups, how many ounces per week Time after waking before first cigarette of the day. (length of time to quit on each occasion) What prompted you to quit on those occasions? What worked for you on those occasions? If you had NRT was it prescribed for you? Did you attend either a group or one to one session? Which cigarette would you miss most after quitting?
Please find attached a smoking diary for you to complete prior to your first appointment and also
information on nicotine addiction and withdrawal symptoms.
I look forward to giving you support during your quit attempt. Please contact the surgery to
make a
20 minute appointment with me, and bring this complete form to that appointment.
Yours sincerely
Chris Day
Practice Nurse
Date completed: ……………………………………
My Smoking Diary

Date of Birth:

To help you prepare for your first few days without tobacco, take some time to complete a
diary sheet. Fill in the first two columns. They will give you lots of information about your
smoking patterns. Now spend some time planning what you can do at those times instead
of smoking.
Reason why I smoke then?
When I stop I plan to?

Daily Amount = …………………….

Congratulations! You have decided that you are ready to stop smoking within the next two
weeks. This action plan will help you make sure you are well prepared to stop smoking
and stay stopped.

Some quick tips:

Get set to STOP
Clean your home and car to get rid of the smell of cigarettes. Get a piggy bank to save the money you currently spend on cigarettes. Draw up a contract of commitment, signed and witnessed.

Change your routine around the times and places you normally smoke. Stay in non-smoking areas as much as possible. Chew sugar-free gum or suck sugar-free sweets. You can do it!
For cravings, find ways to distract yourself or try deep breathing. Don’t try ‘just one’ – it can undo all your hard work. Have a counsellor or friend you can ring for support.
4. ‘What
Plan how you will cope in specific situations. If you have tried before and failed, think about the reasons why and what you could do differently this time. Enjoy your time
Visit ‘no smoking’ cinemas, galleries or restaurants. Read a book, watch a film or play a game. You can STOP!
Record your success in your diary or calendar. If you have a lapse, try again. Remember you can still become a non-smoker. Keep using any therapies as recommended by your doctor or nurse. Write down your personal motivation for stopping smoking overleaf. NICOTINE ADDICTION AND WITHDRAWAL
Expect to experience unpleasant symptoms of nicotine withdrawal. Nicotine replacement therapy blunts these symptoms so behaviour can be changed. Smoking within 20 minutes of waking and/or smoking 20 or more cigarettes a day are suggestive that there is a high nicotine dependency.
Withdrawal Symptoms

Proportion of quitters
Withdrawal Symptom

Contraindications to Nicotine Replacement Therapy (NRT)
• Pregnant
Patients with history of cardiovascular disease, active peptic ulcer, hypertension or diabetes – will be discussed at your first appointment.

Source: http://www.glen-edenmedical.co.uk/assets/pdfs/stop_smoking.pdf

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