Forms

Smoking Status Questionnaire

All fields marked * are required.

Name: *

Date of birth: *

Day: Month: Year:

Do you smoke? *

Yes No

If yes, how often do you smoke? (number per day)

Cigarettes:

Pipe:

Cigars:

Has your GP or nurse given you advice about smoking?

Yes No

If you do not smoke, have you ever smoked?

Yes No

If you would like help and support to stop smoking, the surgery is pleased to offer this service. Please make an appointment with the Practice Nurse.

Thank you for taking the time to complete this form.

Please complete or update the online Contact Preferences Form if you have not already done so.