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

Have you received a letter, text message or verbal invitation to complete this assessment?

Smoking Review

Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
If you smoked, how many cigarettes did you smoke in a day?

Do currently smoke

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

Vaping

Do you currently vape?
Would you like to give up vaping?
Have you ever vaped?
E.g. Monday AM/PM, Tuesday AM/PM
*

Please ask at reception for more information about giving up smoking.