Smoking Review

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

Last Updated: 17/08/2023

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Review Questionnaire

Do you currently smoke? *

Yes No

If 'Yes', when did you stop smoking?

If 'Yes', how many cigarettes do you smoke in a day?

Have you smoked in the past? *

Yes No

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