Smoking Review Smoking Review Personal DetailsFull Name Date of Birth DD slash MM slash YYYY Email Address Please double check you’ve entered the correct email addressPhone NumberSecurity Question (used to identify you):In which month did you last see a Doctor/Nurse at this surgery?Do you take any prescribed medication? Can you tell me what they are?Have you had an operation at hospital? Do you remember when and what for?Answer Smoking ReviewDo you currently smoke? Yes No How many cigarettes do you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Would you like to give up smoking? Yes (please speak to reception) No Privacy Consent I consent to the practice collecting and storing my data from this form.This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.
