Smoking Review Form - The Adam Practice

Email *

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 and to update your records.

I consent to the practice collecting and storing my data from this form.