Skip to content
Clinics & Services
Managing Your Health
About Us
Contact
News
Home
Menu
Clinics & Services
Managing Your Health
About Us
Contact
News
Home
Search
Close
01202 680111
Monday 8:30am – 8pm and Tuesday – Friday 8:30am – 6pm
Smoking Review Form
Lifeboat Quay Medical Centre
>
Managing Your Health
>
Health Review Forms
>
Smoking Review Form
Smoking Review
First Name
*
Last Name
*
Email
*
Enter Email
Confirm Email
*
Confirm 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
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, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our
Privacy Policy
to discover how we protect and manage your submitted data.
*
I consent to the practice collecting and storing my data from this form.
Send
Health A-Z
Guide to conditions, symptoms & treatments
Health A-Z
Live Well
Advice, tips and tools for health & wellbeing
Live Well
Medicines Guide
How medicine works & possible side effects
Medicines A-Z
Care & Support
Options & where to to go to get the best support
Services directory
