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

If you are human, leave this field blank.

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

What date did you stop smoking?

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 visit this site for how to go smoke free to improve your health: www.healthysurrey.org.uk/smoking

Alcohol Consumption

This is one unit of alcohol:

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

How many units of alcohol do you drink per week on average?

1-2

3-4

5-6

7-9

10+

Are you taking any non-prescribed drugs or medication?

Yes

No

Please provide details:

Do you have any concerns about your eating habits?

Yes

No

Please provide details:

*

I confirm that the information provided is accurate to the best of my knowledge

Please ask at reception for more information about giving up smoking.

Submit