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 Full Name: * Date of Birth: * Please use this date format: DD/MM/YYYY. Phone Number: Email Address: * Smoking Review Do you currently smoke? Yes No Do not currently smoke section Have you smoked in the past? Yes No How many cigarettes did you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Do currently smoke section How many cigarettes do you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Would you like to give up smoking? Yes No Please ask at reception for more information about giving up smoking or view the following information at Smokefree NHS, Smokefree.gov or Quit with Help.
