LEMBAR LAPORAN KONSELING BERHENTI

MEROKOK
Konselor: ______________________________
Klien # :_______________________________

1. Karakteristik Demografi:
Nama
:
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Umur
:
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Pendidikan akhir :
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Pekerjaan
:
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2. Status Merokok:
Umur pertama merokok:
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Jumlah batang rokok perhari :
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Jenis rokok: _______________________ harga perbungkus Rp.
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3. Anamnesa:
Derajat ketergantungan merokok (hasil dari Fagerstrom test for Nicotine
Dependence):

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Derajat keinginan untuk berubah (Tahapan perubahan Perilaku
Transtheoritical model):
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4. Faktor yang berperan:
Faktor
individu:___________________________________________________________
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Faktor Lingkungan (keluarga/tetangga/kerja/teman main
dsb.):____________________
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5. Strategi yang disarankan
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6. Prognosa:
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