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

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?

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcoholAmount of different types of drink representing more than one unit of alcohol
How many units of alcohol do you drink per week on average?

Are you taking any non-prescribed drugs or medication?

Do you have any concerns about your eating habits?
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Please ask at reception for more information about giving up smoking.