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Menu
Home
About Us
Contact
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Regulations & Governance
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Know Who to Turn to for Your Healthcare
Referral for Further Care
Self Care Advice
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
Travel Clinic & Holiday Vaccinations
Online Services
NHS App
Register for Online Services
Practice Services
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Keep us up to Date
Health Review Forms
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Smoking Review Form
Smoking Review Form
Smoking Review
First Name
*
Last Name
*
Email
*
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Smoking Status
Do you currently smoke?
*
Yes
No
How many cigarettes do you smoke each day?
1 to 9
10 to 19
20 to 39
40 or more
Would you like to give up smoking?
Yes
No
Did you smoke in the past?
*
Yes
No
How many cigarettes did you smoke each day when you were a smoker?
1 to 9
10 to 19
20 to 39
40 or more
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
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Home
About Us
Contact
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Regulations & Governance
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
Know Who to Turn to for Your Healthcare
Referral for Further Care
Self Care Advice
See a Doctor or Healthcare Professional
Tests & Investigations
Clinics
Travel Clinic & Holiday Vaccinations
Online Services
NHS App
Register for Online Services
Practice Services
Forms
Keep us up to Date
Health Review Forms
Help & Support
News