Prenatal Survey/Fax Referral Form (click here to find your office)
A brief survey for all prenatal patients to fill out at their first prenatal visit. This form serves as 1) A survey to screen for/ identify individual and household smoking status; 2) A fax referral form to the California Smokers’ Helpline for patients who identify themselves as smokers; 3) A guide to be placed in each patient’s medical chart to assist the clinician in giving appropriate advice about tobacco use/exposure; and 4) A guide for the office to determine which education materials to give to each patient.
Patient Education Materials
Prenatal Flyer: English | Spanish
A one-page prenatal flyer designed to be given to ALL pregnant women. This flyer reminds women of the importance of not smoking while they are pregnant or letting anyone smoke near them or their unborn baby. Information about free smoking cessation counseling is also included.
(RQ) Recent Quitters Handouts (series of 4): English | Spanish
A series of 4 tip sheets designed to provide support and encouragement to pregnant women who indicate on their survey that they quit smoking when they found out they were pregnant (Recent Quitters). Each tip sheet offers suggestions to help women stay quit and prepares them for dealing with difficult situations that may tempt them to smoke. While originally designed to be distributed at different points throughout their pregnancy, the entire series can be handed out at once to help motivate recent quitters to stay quit.
(ETS) Environmental Tobacco Smoke Handouts (series of 3): English | Spanish
A serires of 3 handouts designed to inform parents of young children of the harmful effects of secondhand smoke on their child(ren)’s health. Each handout focuses on a specific health complication and the increased risk that infants and children of smokers have of suffering from these negative health outcomes compared to infants and children of non-smokers.
- Sudden Infant Death (SIDS): English | Spanish
- Secondhand Smoke and Childhood Illness: English | Spanish
- Asthma and Smoking: English | Spanish
Program Implementation Materials
Obstetric Office Implementation Procedures
Detailed step-by-step procedures designed to help participating offices become familiar with the program, program materials, and program implementation. All aspects of the program are outlined here to assist and guide participating offices with program implementation.
Steps to Follow: Prenatal Provider Offices
A two-page organization tool designed to help offices successfully implement the PSF program. All the steps from screening patients, faxing referrals, and providing education materials to placing completed surveys in the patients’ medical chart and following-up at subsequent visits are outlined here. Suggestions for when each step should be performed as well as who is in charge of performing which steps are also offered to help offices build the program into their routine and ensure that all aspects of the program are carried out.
Prenatal Advice Grid
An advice grid designed to help providers talk to patients who smoke, recently quit, or are exposed to tobacco smoke at home. These treatment, referral, and follow-up techniques are based on best practice research shown to increase the likelihood of helping patients successfully quit smoking.
Rx: English | Spanish
A prescription-style handout for providers to give to all identified smokers to encourage them to call the California Smokers’ Helpline for smoking cessation services. This should be done in addition to faxing the survey/fax referral form to reinforce the message. (Prints four per sheet: cut after printing).
OB Chart Stickers
A sheet of sticker labels for office members to use to check off the smoking status of the patient and stick on the patient’s chart. Sticker labels serve to 1) remind providers to ask, advise, assist, and follow-up with smokers and recent quitters at each visit; 2) confirm that the patient has completed the Prenatal Survey and been screened for smoking status. (Print on label sheets; prints 30 per sheet)
Print Ads for Health Care Providers
The California Smokers’ Helpline has developed five different print ads to help remind health care providers to Ask patients about their smoking status, Advise them to quit, and Assist patients in quitting by referring them to the Helpline. Click on the links below to access a PDF version of the 8.5” x 11” print ad to display in your office.