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

Section

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.