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?
Please select all that apply:
How many cigarettes did you smoke in a day?
How many cigars did you smoke in a day?

Do currently smoke section

Please select all that apply:
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?

Please ask at reception for more information about giving up smoking.

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