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Kingsway Surgery

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NEW Online Consultations
Covid 19
Appointments
Prescriptions
New Patients
Services
Patient Record
Change of Details form
Online Forms
Health Advice
Social Prescribing
Braunstone Life Article Archive

Language
Home
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Smoking Review Form V3

Smoking Review Form V3

Smoking Review Form V3

Please complete this form to confirm smoking status and to keep your records as up to date as possible.

Smoking Review Form V3

After completing question 4, please complete the rest of the questionnaire if you are a current smoker. If you are a non-smoker, then you do not need to complete anything after question 4. Please go to the end and submit your response.

Patient name:

Patient Date of Birth:

Patient Address, phone number and email:

What is your smoking status?

Current Smoker

Ex Smoker

Never Smoked

What do you smoke?

Cigarette Smoker

Cigar Smoker

Electronic Cigarette

Roll-Up Cigarettes

How Much do you Smoke?

Less than one cigarette a day or equivalent

1-9 cigarettes a day or equivalent

10-19 cigarettes a day or equivalent

20-39 cigarettes a day or equivalent

40+ cigarettes a day or equivalent

Do you want help to stop smoking? Here is some advice on ways to quit smoking, local services and general tips: https://www.nhs.uk/better-health/quit-smoking/

Yes

No

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Page last reviewed: 22 April 2022
Page created: 06 August 2021

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