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Smoking Review Form
Broadwater Farm Surgery
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Health Review Forms
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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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