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Services: Smoking review

Alert

Important patient update: Please read the attached patient letter regarding proposed changes at the practice. The letter is available here.

If you have been advised by the practice to submit a smoking review on a regular basis, please complete this form.

Full name: *Required

Date-of-birth: *Required

Telephone number: *Required

Email address: *Required

Do you currently smoke? *Required Yes No

Smoking/tobacco use

Please provide the following information in relation to smoking (please tick all that apply):

Never smoked tobacco

Ex-smoker Ex-smoker How much (oz/many per day)?

Cigarette smoker Cigarette smoker How much (oz/many per day)?

Cigar smoker Cigar smoker How much (oz/many per day)?

Pipe smoke Pipe smoke How much (oz/many per day)?

Roll own cigarettes Roll own cigarettes How much (oz/many per day)?

Use electronic cigarette Use electronic cigarette How much (oz/many per day)?

Chew tobacco Chew tobacco How much (oz/many per day)?

Other, please specify:

Passive smoking

Are you exposed to smoke at work? *Required Yes No

Are you exposed to smoke at home? *Required Yes No

I agree to the privacy policy.

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gtd healthcare
New Century House
Progress Way
Off Windmill Lane
Denton
M34 2GP

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