Smoking Review

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

You must be registered with this practice to submit this form. 

Smoking Review

Smoking Review

About You

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

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?
If you would like help to stop smoking, please see our Stop Smoking advice section
*
Sending