Smoking Review Form Smoking Review First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * 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 Terms & Conditions By using the forms contained here you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that because of the nature of the Internet we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of communicating with the practice. Personal information is not stored on this system but may be used to update your records with the practice. Send If you are human, leave this field blank.