Smoking Questionnaire Name First Last Date of Birth Day Month Year Contact NumberEmail address Enter Email Confirm Email Smoking StatusDo you smoke? Yes No Have you ever smoked? Yes No When did you quit?How many cigarettes / cigars / ounces of tobacco do you smoke each day?Do you use a vape? Yes No Would you like advice on giving up smoking and/or vaping?We work alongside One Life Suffolk who can offer you support in quitting. Yes No Phone OptionalThis field is for validation purposes and should be left unchanged.
