Type of visit
What is the purpose of this visit?

Household Name

Contact details

Tap "Add" for each person in the household


What is their name?

What is their date of birth or age?

Do they consent to being asked about their smoking?

Do you smoke cigarettes?

How many cigarettes do you smoke per day?

Where on the body?
What actions are needed?


If someone doesn't want to do a skin assessment today write a note to say why and when you will return to do one.

What did you do with the family on your visit today?
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.