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About you

Full name(Required)

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Home address(Required)

Postcode(Required)

Email address(Required)

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Date of birth(Required)

Day

Month

Year

Preferred phone number(Required)

NHS number

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Smoking status

What is your smoking status?(Required)

Current smoker

Ex smoker

Never smoked

How much do you smoke?(Required)

<1 cigarette or gram/day or equivalent

1 to 9 cigarettes or gram/day or equivalent

10 to 19 cigarettes or gram/day or equivalent

20 to 30 cigarettes or gram/day or equivalent

40+ cigarettes or gram/day or equivalent

How long have you smoked?(Required)

Are you interested in advice on how to quit?(Required)

Yes

No

How much did you used to smoke?(Required)

<1 cigarette or gram/day or equivalent

1 to 9 cigarettes or gram/day or equivalent

10 to 19 cigarettes or gram/day or equivalent

20 to 30 cigarettes or gram/day or equivalent

40+ cigarettes or gram/day or equivalent

When did you stop smoking?(Required)

Less than a year ago

More than a year ago

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Date published: 8th August, 2024
Date last updated: 8th August, 2024

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