James Fitzgerald Therapy, PLLC James Fitzgerald, MS, NCC, AAP, Psychotherapist Strengthening Your Conscious Self © 2022 Client Intake: Assessments Fagerstrom Test for Nicotine Dependence Please enable JavaScript in your browser to complete this form.Your therapist will follow standard scoring to calculate score based on responses. Heatherton TF, Kozlowski LT Frecker RC (1991). The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. British Journal of Addiction 86:1119-27.LayoutUser ID (number)DateDo you currently smoke cigarettes? YesNoIf “yes,” read each question below. For each question, enter the answer choice which best describes your response. 1. How soon after you wake up do you smoke your first cigarette?Within 5 minutes6 to 30 minutes31 to 60 minutesAfter 60 minutes2. Do you find it difficult to refrain from smoking in places where it is forbidden?NoYes(e.g., in church, at the library, in the cinema)3. Which cigarette would you hate most to give up?The first one in the morningAny others4. How many cigarettes per day do you smoke?10 or less11 to 2021 to 3031 or more5. Do you smoke more frequently during the first hours after waking than during the rest of the day? NoYes6. Do you smoke when you are so ill that you are in bed most of the day?NoYesComments:Is there anything else about your use that you would like your therapist to be aware of?SubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link