Smoking Review Form

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

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Your Details

Name *

First

Last

Date of Birth *

Phone Number

Email Address *

and day? practice,

Smoking Review

Do you currently smoke? *

• Yes
• No

If 'Yes' How many cigarettes do you smoke in a day? *

• 1 to 9
• 10 to 19
• 20 to 39
• 40 or more

If 'No' Have you smoked in the past? *

• Yes
• No

If 'yes' how many cigarettes did you smoke in a day? *

• 1 to 9
• 10 to 19
• 20 to 39
• 40 or more

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. *

• I consent to the practice collecting and storing my data from this form

Submit