Smoking Review

If you have been advised by the surgery to submit a smoking review on a regular basis please use this form.

Smoking Review

Smoking Review

If you are human, leave this field blank.

Section

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 ask at reception for more information about giving up smoking.

Please note that the details you give will be used to update your medical records.

*

I confirm that the information provided is accurate to the best of my knowledge.