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?
What type? (Please select all applicable)
How many cigarettes did you smoke in a day?
How many cigars did you smoke in a day?

Do currently smoke section

What type? (Please select all applicable)
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?
*
Call the free Smokefree National Helpline to speak to a trained, expert adviser.

Contact 0300 123 1044. All lines are open Monday to Friday 09:00-20:00 and Weekends 11:00-16:00.