Smoking Review

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

Please note we ask for your Sex on this form in order to verify your records with the NHS.

Smoking Review

Smoking Review

Smoking Review

Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Do currently smoke section

How many cigarettes do you smoke in a day?
Would you like to give up smoking?
*
*

Please ask at reception for more information about giving up smoking.