<?xml version="1.0" encoding="UTF-8"?>
<!DOCTYPE FreeMedForms>

<FreeMedForms>

  <formdescription>
    <!-- Non translatable values -->
    <authors>Eric Maeker, MD</authors>
    <version>0.7.1</version>
    <fmfv>0.7.0</fmfv>
    <cdate>2011-03-15</cdate>
    <lmdate>2012-02-26</lmdate>
    <icon>addictology.png</icon>
    <weblink></weblink>
    <bibliography pmid="1932883">Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence : a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86(9):1119-27.</bibliography>

    <!-- Translatable values -->
    <license>GPLv3</license>
    <description lang="fr">Test de Fagerström</description>
    <description lang="xx">Fagerström test</description>
    <category lang="xx">Addictology</category>
    <category lang="fr">Addictologie</category>
    <specialties lang="fr">Addictologie</specialties>
    <specialties lang="xx">Addictology</specialties>

  </formdescription>

  <MedForm name="Subs:Addictology::Smoking::Fagerstrom">
    <label lang="fr">Test de Fagerström</label>
    <label lang="de">Fagerström-Test</label>
    <label lang="xx">Fagerström test</label>
    <options>col=2;DontPrintEmptyValues;UseFormNameAsNameSpace</options>

    <Item name="Wake" type="radio">
      <label lang="fr">Combien de temps après vous être réveillé, fumez-vous votre première cigarette ?</label>
      <label lang="de">Wann nach dem Aufwachen rauchen Sie Ihre erste Zigarette?</label>
      <label lang="xx">How soon after you wake up do you have your first cigarette?</label>
      <options>DontPrintEmptyValues</options>
      <value>
        <uuid id="0">wake0</uuid>
        <uuid id="1">wake1</uuid>
        <uuid id="2">wake2</uuid>
        <uuid id="3">wake3</uuid>
        <possible id="0" lang="fr">moins de 5 minutes</possible>
        <possible id="1" lang="fr">entre 6 et 30 minutes</possible>
        <possible id="2" lang="fr">entre 31 et 60 minutes</possible>
        <possible id="3" lang="fr">après 60 minutes</possible>
        <possible id="0" lang="de">innerhalb von 5 min</possible>
        <possible id="1" lang="de">6 ... 30 min</possible>
        <possible id="2" lang="de">31 ... 60 min</possible>
        <possible id="3" lang="de">nach 60 min</possible>
        <possible id="0" lang="xx">Within 5 minutes</possible>
        <possible id="1" lang="xx">6-30 minutes</possible>
        <possible id="2" lang="xx">31-60 minutes</possible>
        <possible id="3" lang="xx">After 60 minutes</possible>
        <numerical id="0">3</numerical>
        <numerical id="1">2</numerical>
        <numerical id="2">1</numerical>
        <numerical id="3">0</numerical>
      </value>
    </Item>

    <Item name="Refrain" type="radio">
      <label lang="fr">Trouvez-vous difficile de ne pas fumer dans les endroits interdits (ex: cinémas, bibliothèques...) ?</label>
      <label lang="de">Finden Sie es schwierig, an Orten, wo das Rauchen verboten ist  (z.B. Kirche, Bücherei, Kino usw.), das Rauchen zu lassen?</label>
      <label lang="xx">Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, the library, the cinema, etc?</label>
      <options>DontPrintEmptyValues</options>
      <value>
        <uuid id="0">refrain0</uuid>
        <uuid id="1">refrain1</uuid>
        <possible id="0" lang="fr">oui</possible>
        <possible id="1" lang="fr">non</possible>
        <possible id="0" lang="de">ja</possible>
        <possible id="1" lang="de">nein</possible>
        <possible id="0" lang="xx">yes</possible>
        <possible id="1" lang="xx">no</possible>
        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
      </value>
    </Item>

    <Item name="GiveUp" type="radio">
      <label lang="fr">Quelle cigarette trouvez-vous la plus indispensable ?</label>
      <label lang="de">Auf welche Zigarette würden Sie verzichten wollen?</label>
      <label lang="xx">Which cigarette would you hate most to give up?</label>
      <options>DontPrintEmptyValues</options>
      <value>
        <uuid id="0">giveup0</uuid>
        <uuid id="1">giveup1</uuid>
        <possible id="0" lang="fr">la première</possible>
        <possible id="1" lang="fr">une autre</possible>
        <possible id="0" lang="de">die erste am Morgen</possible>
        <possible id="1" lang="de">andere</possible>
        <possible id="0" lang="xx">The first one in the morning</possible>
        <possible id="1" lang="xx">All others</possible>
        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
      </value>
    </Item>

    <Item name="Amount" type="radio">
      <label lang="fr">Combien de cigarettes fumez-vous par jour en moyenne ?</label>
      <label lang="de">Wieviele Zigaretten rauchen Sie im allgemeinen pro Tag?</label>
      <label lang="xx">How many cigarettes do you smoke per day?</label>
      <options>DontPrintEmptyValues</options>
      <value>
        <uuid id="0">amount0</uuid>
        <uuid id="1">amount1</uuid>
        <uuid id="2">amount2</uuid>
        <uuid id="3">amount3</uuid>
        <possible id="0" lang="fr">10 ou moins</possible>
        <possible id="1" lang="fr">entre 11 et 20</possible>
        <possible id="2" lang="fr">entre 21 et 30</possible>
        <possible id="3" lang="fr">31 ou plus</possible>
        <possible id="0" lang="de">bis 10</possible>
        <possible id="1" lang="de">11 ··· 20</possible>
        <possible id="2" lang="de">21 ··· 30</possible>
        <possible id="3" lang="de">31 und mehr</possible>
        <possible id="0" lang="xx">10 or fewer</possible>
        <possible id="1" lang="xx">11-20</possible>
        <possible id="2" lang="xx">21-30</possible>
        <possible id="3" lang="xx">31 or more</possible>
        <numerical id="0">0</numerical>
        <numerical id="1">1</numerical>
        <numerical id="2">2</numerical>
        <numerical id="3">3</numerical>
      </value>
    </Item>

    <Item name="FirstHour" type="radio">
      <label lang="fr">Fumez-vous de façon plus rapprochée dans la première heure après le réveil que pendant le reste de la journée ?</label>
      <label lang="de">Rauchen Sie am Morgen im allgemeinen mehr als am Rest des Tages?</label>
      <label lang="xx">Do you smoke more often during the first hours after waking than during the rest of the day?</label>
      <options>DontPrintEmptyValues</options>
      <value>
        <uuid id="0">firsthour0</uuid>
        <uuid id="1">firsthour1</uuid>
        <possible id="0" lang="fr">oui</possible>
        <possible id="1" lang="fr">non</possible>
        <possible id="0" lang="de">ja</possible>
        <possible id="1" lang="de">nein</possible>
        <possible id="0" lang="xx">yes</possible>
        <possible id="1" lang="xx">no</possible>
        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
      </value>
    </Item>

    <Item name="EvenIll" type="radio">
      <label lang="fr">Fumez-vous même si une maladie vous oblige à rester au lit ?</label>
      <label lang="de">Kommt es vor, dass Sie rauchen, wenn Sie krank sind und tagsüber im Bett bleiben müssen?</label>
      <label lang="xx">Do you smoke even if you are so ill that you are in bed most of the day?</label>
      <options>DontPrintEmptyValues</options>
      <value>
        <uuid id="0">evenill0</uuid>
        <uuid id="1">evenill1</uuid>
        <possible id="0" lang="fr">oui</possible>
        <possible id="1" lang="fr">non</possible>
        <possible id="0" lang="de">ja</possible>
        <possible id="1" lang="de">nein</possible>
        <possible id="0" lang="xx">yes</possible>
        <possible id="1" lang="xx">no</possible>
        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
      </value>
    </Item>

    <Item name="Score" type="sum">
      <label lang="fr">Score</label>
      <label lang="de">Gäste</label>
      <label lang="xx">Score</label>
      <sumof_regexp>Subs:Addictology::Smoking::Fagerstrom::*</sumof_regexp>
      <options>DontPrintEmptyValues;changeepisodelabel</options>
    </Item>

    <Item name="ScoreInterpretation" type="helptext">
      <label lang="fr">0-2 : Très faible&lt;br />3-4 : Faible&lt;br />5 : Moyenne&lt;br />6-7 : Forte&lt;br />8-10 : Très forte&lt;br /></label>
      <label lang="de">0-2: Sehr niedrig&lt;br /> 3-4: Niedrige&lt;br /> 5: Durchschnittliche&lt;br /> 6-7: Starke&lt;br /> 8-10: Sehr hohe&lt;br /></label>
      <label lang="xx">0-2: Very Low&lt;br /> 3-4: Low&lt;br /> 5: Average&lt;br /> 6-7: Strong&lt;br /> 8-10: Very high&lt;br /></label>
      <options>notprintable</options>
    </Item>

  </MedForm>

</FreeMedForms>
