Smoking Status

To help us update your patient records with your smoking status, please take a couple of minutes to fill in our smoking questionnaire.

Please complete the questionnaire whether you smoke, are an ex smoker or a non smoker.

About You

Name

First Name Surname

Date of birth

What is your Smoking Status?

I am a current Smoker

I used to smoke but have now given up

I have never smoked

Current Smoker

When did you start Smoking?

What and how often do you smoke?

Provide as much information as you can about your smoking. Include details of what you smoke (Cigars, Cigarettes, Pipe etc) and how often.

Would you like our assistance in helping you to stop smoking?

Yes

Ex Smoker

When did you start Smoking?

When did you stop Smoking?

Tell us more about your smoking history

Provide as much information as you can about your smoking. Include details of what you smoked (Cigars, Cigarettes, Pipe etc) and how often.

Privacy

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.

The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible. We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. If you are not completely happy to provide information via the internet please contact the practice directly.

I consent to the practice collecting and storing my data from this form.