To be completed by Patient
Please answer all questions honestly; your answers will be kept confidential.
During the PAST 12 MONTHS, on how many days did you:
READ THESE INSTRUCTIONS BEFORE CONTINUING
If you put “0” in ALL of the boxes above, ANSWER QUESTION 5 BELOW, THEN STOP
If you put “1” or more for Questions 1, 2, or 3 above, ANSWER QUESTIONS 5-10 BELOW
If you put “1” or more for Question 4 above, ANSWER ALL QUESTIONS
The following questions ask about your use of any vaping devices containing nicotine
and/or flavors or use of any tobacco products. Select your answer for each question.
7. When you HAVEN’T vaped or used tobacco in a while (or when you tried to stop using)…
Wheeler, K. C., Fletcher, K. E., Wellman, R. J., & DiFranza, J. R. (2004). Screening adolescents for nicotine dependence: the Hooked
On Nicotine Checklist. J Adolesc Health, 35(3), 225–230;
McKelvey, K., Baiocchi, M., & Halpern-Felsher, B. (2018). Adolescents’ and Young Adults’ Use and Perceptions of Pod-Based Electronic
Cigarettes. JAMA Network Open, 1(6), e183535.
NOTICE TO CLINIC STAFF AND MEDICAL RECORDS:
The information on this page is protected by special federal confidentiality rules (42 CFR Part 2), which prohibit disclosure of this information unless
authorized by specific written consent.
© John R. Knight, MD, Boston Children’s Hospital, 2020.
Reproduced with permission from the Center for Adolescent Behavioral Health Research (CABHRe), Boston Children’s Hospital.
For more information and versions in other languages, see www.crafft.org