If you have been advised by the surgery to submit a smoking review on a regular basis please use this form. Find out more about our Smoking Cessation services…

Smoking Review

About You

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

Smoking Review

Do you currently smoke?

Yes

No

Do not currently smoke section

Have you smoked in the past?

Yes

No

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Do currently smoke section

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

No

Please contact Reception for more information about giving up smoking.