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Form Details

• Form Properties
  1. Form Title: Fagerstrom Test for Cigarette Dependence v2
  2. Start from an Existing Form - Yes, if there is a previous assessment signed and locked.
  3. Copyrighted Form - Yes. Copyright © 1991, Karl Fagerstrom
  4. Billable Progress Note - No
  5. Have multiple versions open at same time - No
  6. Open Blank on new version - No
• Required Fields - Yes
• Lookup Tables - No
• Pre-Fill Logic- None
• Fill to Logic - None
• Signatures
  1. Patient Signature
     • Sig type: Patient
  2. Staff Signature
     • Credential required to sign: any sig type.
     • Title will fill title entered in user setup (see eCR University - Users).
     • Signature required.
  3. Supervisor Signature
     • Credential required to sign: Supervisor.
     • Title will fill from title entered in user setup (see eCR University - Users).
     • Defaults to N/A checked.

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Questions Tab

1. Enter Segment, Visit Number, and Date of Assessment.
2. Complete section by selecting the appropriate options.
3. The section will populate based off the selections made in section 2.

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Comments Tab

1. Add any necessary comments.
2. Patient Signature
   • Sig type: Patient
3. Staff Signature
   • Credential required to sign: any sig type.
   • Title will fill title entered in user setup (see eCR University - Users).
   • Signature required.
4. Supervisor Signature
   • Credential required to sign: Supervisor.
   • Title will fill from title entered in user setup (see eCR University - Users).
   • Defaults to N/A checked.

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