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

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?

For more information about how to quit, advice and support, please visit the Wellbeing Centre.

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