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

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

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

Can our Nurse call you to discuss giving up smoking?
How many cigarettes do you smoke in a day?
Would you like help to give up smoking?

Please visit or phone 0800 0130553 for support and advice. Alternatively, you may be requested to have an appointment by one of our nurses.