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

About You

Please use this date format: DD/MM/YYYY.
Can we contact you by email?
Can we contact you by text message?

Smoking Review

Do you currently smoke?
How many cigarettes do you smoke in a day?
Would you like to give up smoking?
Would you like a referral with one of our smoking cessation advisors?

Do not currently smoke section

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

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