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

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Smoking Review

Do you currently smoke?
Do you smoke:

Do not currently smoke section

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

Do currently smoke section

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

For more information and advice on how to quit smoking, please www.nhs.uk/live-well.

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