Required field(s) are indicated by * Smoking Review Smoking Review If you are human, leave this field blank. Are you completing this form on behalf of: Yourself Someone else (e.g. a child or dependent) About you Your First Name(s): * First Name(s) as appears on your passport. Your Last Name: * Last Name(s) as appears on your passport. Postcode: * The one used to register with your GP. Your Date of Birth: * Your date of birth is required to verify your identity. Sex: * Male Female Other As on your medical record. As on your medical record. Your Phone Number: * The practice may use this number to contact you about your request. Your Email: * This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you. Please continue completing the form below Smoking Review Do you currently smoke? Yes No Do not currently smoke section Have you smoked in the past? Yes No How many cigarettes did you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Do currently smoke section How many cigarettes do you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Would you like to give up smoking? Yes No * I confirm that the information provided is accurate to the best of my knowledge Please ask at reception for more information about giving up smoking.