Smoking Review Form - Wycliffe Surgery

Do you currently smoke? *

Yes No

If 'Yes' How many do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

If 'No' Have you smoked in the past?

Yes No

If you are a smoker and you would like information or help with stopping smoking

Consider calling the surgery to book an appointment with one of our Smoking Cessation Nurses

Consider visiting the NHS smoke free website on https://www.nhs.uk/smokefree/

Keep these options in mind for future if you are not quite ready to quit

THIS FORM COLLECTS PERSONAL AND MEDICAL DETAILS AS ABOVE. PLEASE CONFIRM YOU ARE REGISTERED WITH WYCLIFFE SURGERY AND THAT YOU CONSENT TO THE PRACTICE TEAM UPDATING YOUR NHS MEDICAL RECORDS. IF YOU WOULD LIKE TO KNOW HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA, PLEASE READ OUR PRIVACY POLICY. *

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

Smoking Review Wycliffe

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Smoking Review Wycliffe

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