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 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.

Sending