Clean Air for Healthy Children & Families : Section


		Patient Materials
		Practice Materials
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Clean Air for Healthy Children and Families
PA Chapter AAP
Rose Tree Corporate Center II
1400 N. Providence Road
Suite 3007
Media, PA 19063

PH: 484-446-3002
Fax: 484-446-3255
800-375-5217 (PA Only)

E-mail
www.paaap.org

	PRACTICE MATERIALS


	These materials are available to make implementing the program into your office routine a smooth transition and a successful one. Incorporating practice tools can increase the likelihood that staff will query about smoking status and document the intervention. Non-Smoking Chart Stickers Chart sticker that indicates a patient as a non-smoking individual. Sticker should be printed on Avery Labels 5732. Smoking Chart Sticker Chart sticker that indicates a patient as a smoking individual. Sticker should be printed on Avery Labels 5732. Smoking Cessation Counseling Documentation Cover Letter Use this cover letter to accompany Smoking Cessation Counseling Documentation Forms when sending into the main office Smoking Cessation Counseling Documentation Form (English) Documents the 5 A's intervention on a 8.5x11 sheet that logs 6 office visits. Smoking Cessation Couseling Documentation Chart Sticker Documents the 5 A's intervention on a fluorescent 3x2 sticker. Please use Avery 5199-F Smoking History Survey for Patient, Parent, and Caregiver (English) To be used at the first visit to assess the general patient's smoking status, barriers, household environment and addictivity level. Smoking History Survey for Pregnant Women (English) To be used at the first visit to assess the pregnant patient's smoking status, barriers, household environment and level of addiction TSP - Smoking in House Chart Stickers Chart sticker that indicates Tobacco Smoke Pollution in the household. Stickers should be printed on Avery Labels 5732.

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