Smoking Review Form

Do you currently smoke? *

Yes No

If 'No' Have you smoked in the past?

Yes No

For past smokers. ' How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

For current smokers. What is your preferred smoking option? Please tick the following that apply to you: *

Cigarettes

Roll own cigarettes

Cigars

Pipe Smoker

Waterpipe tobacco consumption

Cigarette Smoker? ' How many cigarettes do you smoke in a day?

Roll your own cigarettes? How many grams do you smoke per week?

Cigar Smoker? How many cigars do you smoke in a day?

Pipe Smoker? How many grams of tobacco do you smoke per week?

Waterpipe tobacco consumption? How many times do you use this per week?

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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Smoking Review Form

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