Smoking Review

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

Please be aware that these forms are processed by the senior management team who are not medically trained.

Smoking Review

Smoking Review

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.