Smoking Review

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

All messages will receive an email response (to the input address) – please check your email address given and junk/spam folder if you do not receive a response.

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.