NRT Supply & Patient’s Name Monitoring Week 1 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per Levy Collected (Y/N) FP10) Name of staff member delivering the service: Notes: Week 2 Date Last Smoked: CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per Levy Collected (Y/N) FP10) Name of Staff member delivering the service: Week 3 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per Levy Collected (Y/N) FP10) Name of staff member delivering the service: Notes: Week 4 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per Levy Collected (Y/N) FP10) Four Week Quit Achieved Yes/No Patient Referred Yes/ No Name of staff member delivering the service: Notes: Week 5&6 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per Levy Collected (Y/N) FP10)
NRT Supply & Monitoring Patient’s Name Week 1 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per FP10) Levy Collected (Y/N) Name of staff member delivering the service: Notes: Week 2 Date Last Smoked: CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per FP10) Levy Collected (Y/N) Name of Staff member delivering the service: Week 3 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per FP10) Levy Collected (Y/N) Name of staff member delivering the service: Notes: Week 4 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per FP10) Levy Collected (Y/N) Four Week Quit Achieved Yes/No Patient Referred Yes/ No Name of staff member delivering the service: Notes: Week 5&6 Date Last Smoked CO reading (mmol/l) NRT Product 1 Quantity Product 2 Quantity Prescription levy Status (Please indicated B-S as per FP10) Levy Collected (Y/N)