California Smoker’s Helpline
NRT Screening (Enhanced Services)
Form Approved
OMB No. 0920-0856
Exp. Date xx/xx/XXXX
National Quitline Data Warehouse
Intake Questionnaire
(Asian Smoker’s Quitline: Chinese)
Public reporting burden of this collection of information is estimated to range from 1-10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0856)
Asian Smokers’ Quitline (ASQ) Chinese Intake
This is a free service to help people quit smoking. We offer help through the mail and also over the phone. To provide the best possible service, calls may be monitored and recorded, but will be kept private. I need to ask you a few questions to see what we can do for you, and all of your responses are voluntary. Is that OK?
這裡是提供免費協助戒煙的服務中心，由加州大學醫學院管理。我們的服務都是通過郵寄和電話提供的。為了提供最佳服務, 談話可能被旁聽和錄音。我想先問您一些問題，您的回答純屬自願，也就是說您有權不回答任何問題。您所有的回答都是保密的，可以嗎？ Yes No
1) Are you calling for yourself or someone else? 您打電話來, 是您自己要戒煙, 還是為別人索取資料？
Yourself Someone else
2) What’s your year of birth? 請問您的出生年月日?
_______ Refused
IF REFUSED: Then how old are you?
那您今年幾歲？ _________ Refused Unwilling, but >= 18 yrs. old
3) How did you hear about us? 您是怎麼知道我們這個中心及所提供的服務？
Ads: TV Radio Newspaper/ Magazine
Billboard/ Bus Sign
Phone Book Web
Referrals: VA Hospital Clinic/ Doctor’s Office
Dentist/ Dental Hygienist
Friend/ Family
WIC
Pharmacy School Non-profit Org.
Insurance/HMO/MediCal Other
Don’t know
Refused
Promotional Materials
Card (Gold, Salud, Quit Now)
Patch Voucher
Brochure/Pamphlet
Postcard
If any Referral source (e.g. VA through Insurance/HMO/MediCal above):
Did you receive anything, such as a card or brochure with our number on it?
您曾收到一張有我們電話號碼的卡片或小冊子嗎？
No Yes…Postcard Yes…Re-engagement letter
Yes… Card Yes…Magnet Don’t Know
Yes…Patch Voucher Yes…Brochure/ Pamphlet Refused
If PROMOTIONAL MATERIALS:
您是從哪裏拿到金卡/小冊子/章程的呢？
VA Hospital Clinic/ Doctor’s Office
Dentist/ Dental Hygienist Friend/ Family WIC
Pharmacy School Non-profit Org.
Insurance/HMO/MediCal CSH Other
4) Do you smoke cigarettes every day, some days, or not at all (already quit)?
您每天都抽煙,有些日子抽煙，還是完全不抽呢?
Every day
Some Days…
Not at all (already quit)…
Other form of tobacco…
a. If EVERY DAY: On average, how many cigarettes do you smoke per day?_
平均來講，您每天抽幾支煙 ? ____ Don’t know Refused
Do you usually smoke menthol or non-menthol cigarettes?
您通常抽薄荷味道還是沒有薄荷味道的香煙？
Menthol Non-menthol No usual type Don’t know Refused Not asked
b. If SOME DAYS: How many days per week do you smoke?
您每週有幾天吸煙 ? ______ Refused
On average how many cigarettes do you smoke per day on the days you smoke?
平均來講，在你抽煙的日子您每天抽幾支煙 ?______ Refused
Do you usually smoke menthol or non-menthol cigarettes?
您通常抽薄荷味道還是沒有薄荷味道的香煙？
Menthol Non-menthol No usual type Don’t know Refused Not asked
c. If NOT AT ALL: When did you quit? 什麼時候戒的煙？ _______/_______/_______ Don’t know Refused
How many days per week did you smoke? 戒煙以前，您每一個星期有幾天抽煙?______
Don’t know Refused
On average how many cigarettes did you smoke per day on the days you smoked? 在您抽煙的日子，平均來講每天會抽幾枝煙？______
Don’t know Refused
Did you usually smoke menthol or non-menthol cigarettes?
您通常抽薄荷味道還是沒有薄荷味道的香煙？
Menthol Non-menthol No usual type Don’t know Refused Not asked
5) How soon after you wake up do/did you usually smoke
your first cigarette?
每天早上醒來後，您大約多久以後抽第一支煙？
0-5 mins 6-30 mins 31-60 mins +60 mins Don’t know Refused
6a) Do you currently use any other form of tobacco, such as chew/snuff, cigars, or pipes? 現在您有沒有使用其他煙草？ （例如咀嚼煙，鼻煙，雪茄或煙斗）？
Yes … No …
Don’t know … Refused…
6b) Do you currently use any other form of tobacco, such as chew/snuff, cigars, or pipes?
現在您有沒有使用其他煙草？ （例如咀嚼煙，鼻煙，雪茄或煙斗）？
Yes … No … Don’t know Refused…
6c) Which ones?哪幾種?
Chew/snuff Cigarillos (小雪茄) Cigars Pipes Hookah (水煙筒) Other: ________
If CHEW/SNUFF: M How much tobacco do you use per week?
每個星期用多少？ _____
Is that cans or pouches? 是罐還是袋？ Don’t know Refused
If NO to current use (7b): When did you quit? 甚麼時候戒的呢?_____/_____/______
Refused
If CIGARS: M How many do you smoke per week? 每個星期抽幾枝？______________
Don’t know Refused
7) Have you ever used an e-cigarette? 你使用過電子煙嗎？
Yes…
No…
Don’t know
Refused
Not asked
Do you currently use e-cigarettes every day, some days, or not at all?
你現在是每天用電子煙，有些日子用，還是不再用了？
Every day…
Some days….
Not at all…
Don’t know
Refused
Not asked
When was the last time you used an e-cigarette?
你最後一次使用電子煙是在甚麼時候？
____/____/________.
Don’t know…
Refused….
Not asked …
In the last 30 days, how many days did you use an e-cigarette?
______ days (0-30)
過去的30天你有幾天使用電子煙？
Don’t know
Refused
Not asked
Do you think you will quit using e-cigarettes within 1 year?
你會在一年之内把電子煙戒斷嗎？
Yes…
No…
Don’t know…
Refused…
Not
asked…
Do you think you will quit within a month, within 6 months, or after 6 months?
你會在一個月内，六個月内還是六個月後戒呢？
Within a month
Within 6 months
After 6 months
Don’t know
Refused
Not asked
8) One of two options depending if AQ or not:
a) IF ALREADY QUIT: Are you currently using the nicotine gum, patch, or Zyban or Chantix? 現在您有使用尼古丁口香糖，貼片、 Zyban 或是Chantix 嗎？
Yes No Don’t know Refused
b) If YES: Which ones? 哪幾種?
Patch Gum Zyban Chantix Other: ________
c) IF NOT ALREADY QUIT: Do you plan to quit smoking within a month?
您打算在一個月之内戒煙嗎？
Yes No Don’t know Refused
9) Do you plan to use any quitting aids such as the nicotine gum, patch, or Zyban or Chantix to help you quit this time? 這次戒煙，你有打算用任何輔助藥物，例如尼古丁貼片，口香糖，Zyban或 Chantix來幫助你嗎？
Yes No Don’t Know Refused
If YES: Which ones? 哪幾種? Patch Gum Zyban Chantix
Other: ___
10) Do you have any form of health insurance, such as Kaiser or MediCal?
你有醫療保險嗎？例如：Kaiser或政府保險計劃
Yes No Don’t know Refused
IF YES: What is the plan name? 是哪一個保健計劃? ______
Now I have a few health questions that are related to smoking.
現在我想問您幾個可能因吸煙引起的健康問題
11) Have you ever been told by a doctor that you have HIGH BLOOD PRESSURE?
醫生說過您有高血壓嗎？
Yes No Don’t know Refused
IF YES: Is it under control? 有沒有用藥物來控制呢?
Yes, with medication
Yes, w/o medication
No, not controlled
Don’t know
Refused
12) Have you ever been told by a doctor that you have DIABETES醫生說過您有糖尿病嗎？
Yes No Don’t know Refused
If YES: Do you use insulin or take pills for it? 你是用胰島素還是用藥丸控制的呢？
Yes, pills
Yes, insulin
Yes, both pills and insulin
No, neither pills nor insulin
Don’t know
Refused
13) Have you ever had a heart attack? 您曾有過心臟病發作嗎？
Yes No Don’t know Refused
If YES: Was it within the last 6 months? 發生在過去六個月之内嗎？
Yes No Don’t know Refused
14) Have you ever had a stroke? 有過中風嗎？
Yes No Don’t know Refused
If YES: Was it within the last 6 months? 發生在過去六個月之内嗎?
Yes No Don’t know Refused
15) We send free materials to everyone, so may I have your zip code? 我們會把免費的戒煙資料寄給您，請問您的郵政編碼是幾號？____________
16) I have a few demographic questions. First, I need to verify…Are you male or female?
我們還有幾個簡單的問題想問問您。首先,
我們需要確實一下您的性別， 您是男/女性, 對嗎？
Male Female Refused Not asked
If FEMALE and </= 45 yrs. old: We also have special information for pregnant clients, is there any chance you may be pregnant? 我們也有一些給孕婦的特別資料，請問你現在有懷孕嗎？
No Yes Don’t know Refused Not asked
If YES: When is your baby due? 預產期是在甚麼時候？
____/____/____ DK R Not asked
17) What is your racial background?
您屬於哪個族裔？
White Black/African American
Asian/ Pacific Islander
What is your specific Asian background? (drop down menu)
是亞裔中哪一個族裔？
Native Hawaiian/Other Pacific Islander
American Indian or Alaska Native
More than one of the above
Check ANY/ALL that apply:
White
Asian
What is your specific Asian background? (drop down menu)
是亞裔中哪一個族裔？
Native Hawaiian/Other Pacific Islander
Black/African American
American Indian/Alaska Native (tribe menu)
Other ____________________
17b) What is your ethnic background? 您屬於哪個族裔？
Hispanic/Latino Not Hispanic/Latino
18a) In which country were you born?你是在哪一個國家出生呢？
U.S. Other
Korea Don’t know
Vietnam Refused
China Not asked
18b) What year did you come to U.S?你是在哪一年來美國的？____ Don’t know Refused
19) What is the highest level of education that you have completed?
請問您的教育程度是甚麼？
Never attended school 2-yr College degree (AA)
Grades 1-8 4-yr, College or Univ degree (BA, BS)
Grades 9-12 (No Diploma) Post-Graduate degree (Masters, Ph.D)
GED Refused
High School Diploma Don’t know
Some College or Trade School, No Degree Not asked
20) What is the age of the youngest person in your household? ________ D R Z
現在跟您一起住的家人中， 年紀最小的今年幾歲？
21) Have you been told you have arrhythmia (an irregular heart beat/rhythm that requires medication)? 你曾經有心律不齊需要服藥嗎？
Yes No
22) Have you been told you have angina (serious heart pain/chest pain with exertion)? 你曾經有心絞痛嗎？（嚴重的心疼痛/胸口痛及發緊）
Yes No
Don’t know Refused
23) Have you ever had an allergic reaction to adhesive tape? 貼膠布後曾經有過敏的反應嗎？
Yes, severe (problems breathing or hospitalization)
Yes, mild (rash)
No
Don’t know
Refused
24a) What dosage are you on?你用的是什麽劑量呢？
If patch: 21 mg (Step 1)
14 mg (Step 2)
7 mg (Step 3)
Don’t know
Refused
24b) What dosage are you on? 你用的是什麽劑量呢？
If gum: 4 mg
2 mg
Don’t know
Refused
If has medical contraindications (any box needing MD OK checked) :
25) We need to get a Doctor’s OK for you to use patches. Is that OK? 我們需要先得到您的醫生的允許才可以讓您使用貼片，您覺得可以嗎？
Yes (Ok to contact MD)
Doesn’t have an MD (Ok from an MD will be required)
No (Not ok to contact MD —client will be ineligible)… go to ineligible ending
If Yes…
What is his/her name? (or clinic/hospital name?) 他/她叫甚麼名字？(或診所/醫院的名字？）
Name______________________ _______________ Don’t know Refused
And the phone Number? 電話號碼呢？
_______________________ Don’t know Refused
Do you happen to know the fax number? 您有他/她的傳真號碼嗎？_____________________ Don’t know Refused
26a) If Ok to get MD consent, but no MD or Don’t Know
If you call us back with your MD phone or fax number, you may be able to receive patches sent directly to you. Or, in most cases, Medi-Cal will pay for the patches or other quitting aids if you have two things:
在取得你的醫生的電話或者傳真號碼後，打電話來你就有可能直接收到貼片。或你有這兩張文件：
A prescription from your doctor 醫生的處方及戒煙專綫的證書一併拿到藥房
A certificate from us
Take these to your pharmacy.
大多數的情況白卡都會支付尼古丁貼片或其他戒煙輔助藥的費用。
26b) If Not okay to get MD consent:
Ok, we still want to offer you our free phone counseling. The session is about a half hour and helps you prepare to quit/stay quit. Would you like to speak to a smoking cessation counselor?
好吧，這樣我們還是可以提供給您大概30分鐘免費的電話諮詢，戒煙顧問會幫助您了解怎樣準備戒煙/保持不再抽煙。您願意跟我們的顧問談話嗎？
Yes (counseling) No (materials)
27) We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year?
在一年內，我們希望能和一小部分曾經打電話來的人士通電話，以便了解我們服務的成效。到時候，我們可以打電話給您嗎?
Yes No Refused Not asked
You’ll be receiving your materials in the mail in about a week and we’ll let you know when we hear from your doctor.
大約一個星期左右，您將會收到我們寄給您的戒煙資料，當我們接到您醫生的囘覆時，我們會再通知您。
The next step is to talk with a smoking cessation counselor for about 30 minutes and they’ll help you prepare to quit/stay quit. Do you have time to do the counseling now if a counselor is available?
下一步是跟戒煙顧問交談， 戒煙顧問會幫助您準備戒煙/保持不再抽煙。假如我們的戒煙顧問現在有空，您有沒有大概30 分鐘的時間談話呢？
Yes Let me see if one is available讓我先看看有沒有顧問有空 . . . Available
No… Not available
Refused Counseling …
If no medical contraindications:
28) We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? (skip this consent question for cx’s that refuse ph# or no phone # is given) 在一年內，我們希望能和一小部分曾經打電話來的人士通電話，以便了解我們服務的成效。到時候，我們可以打電話給您嗎?
Yes No Refused Not asked
You’ll be receiving your materials and patches in the mail in about a week, and by the way, they will come separately. 大約一個星期左右，您將會收到兩個分別裝有戒煙資料及尼古丁的包裹。
The next step is to speak with a smoking cessation counselor for about 30 minutes and they’ll help you prepare to quit/stay quit. Do you have time to do the counseling now if a counselor is available?
下一步是跟戒煙顧問交談，戒煙顧問會幫助您準備戒煙/保持不再抽煙。
假如戒煙顧問現在有空，您有沒有大概30 分鐘的時間談話呢？
Yes Let me see if one is available讓我先看看有沒有顧問有空…. Available
No… Not available
Refused Counseling …
If not eligible for NRT (e.g., no phone, address, no voucher #, etc):
a.We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內，我們希望能和一小部分曾經打電話來的人士通電話，以便了解我們服務的成效。到時候，我們可以打電話給您嗎?
Yes No Refused Not asked
b.You’ll be receiving your materials in the mail in about a week. Do you have time to do the counseling now if a counselor is available? 大約一星期左右，您就會收到戒煙資料。您現在有時間跟戒煙顧問談談有關戒煙的問題嗎?
Yes No Not asked
29) No (materials only)
We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內，我們希望能和一小部分曾經打電話來的人士通電話，以便了解我們服務的成效。到時候，我們可以打電話給您嗎?
Yes No Refused Not asked
You’ll be receiving your materials in the mail in about a week. If you would like to receive counseling in the future, you can always call us back. (結束語...) 大約一星期左右，您就會收到戒煙資料。如果您將來覺得需要跟戒煙顧問談談，請隨時打電話給我們。
30) We offer help over the phone. The session is about a half hour and helps you prepare to quit/stay quit. Would you like to speak to a smoking cessation counselor? 我們提供約30 分鐘的電話戒煙輔導，戒煙顧問可以幫助您預備如何戒煙/保持不再抽煙。您願意跟他談談嗎？
Yes (counseling) No (materials)
Yes (counseling)
a.We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內，我們希望能和一小部分曾經打電話來的人士通電話，以便了解我們服務的成效。到時候，我們可以打電話給您嗎?
Yes No Refused Not asked
b.You’ll be receiving your materials in the mail in about a week. Do you have time to do the counseling now if a counselor is available? (結束語...) 大約一星期左右，您就會收到戒煙資料。您現在有時間跟戒煙顧問談談有關戒煙的問題嗎？
Yes No Not asked
No (materials only)
We like to call back a small number of people to see how well our services work over time. Would it be alright to contact you sometime in the next year? 在一年內，我們希望能和一小部分曾經打電話來的人士通電話，以便了解我們服務的成效。到時候，我們可以打電話給您嗎?
Yes No Refused Not asked
You’ll be receiving your materials in the mail in about a week. If you would like to receive counseling in the future, you can always call us back.
(結束語...) 大約一星期左右，您就會收到戒煙資料。如果您將來覺得需要跟戒煙顧問談談，請隨時打電話給我.
Updated 07/13/2012 Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | California Smoker’s Helpline |
| Author | anne |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |