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

If you currently do not have a fixed address, please enter in the address field no fixed abode. If you are changing your address, please enter your old address in this section.

Smoking Review

Do you currently smoke?
How many cigarettes do you smoke in a day?

Do not currently smoke section

How many cigarettes did you smoke in a day?
Have you smoked in the past?

Do currently smoke section

Would you like us to contact you with details about support for stopping smoking? *