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

Section

Ethnicity

Please specify the ethnic group you consider you belong to: *

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

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

Join the millions of people who have used Smokefree support to help them stop smoking. From email and text, to our free app and lots of other support, you can choose what’s right for you. For more information visit the Smokefree website.

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