Smoking Review

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If you have been advised by the surgery to submit a smoking review on a regular basis please use this form.

Smoking Review

Smoking Review

About You

Please use this date format: DD/MM/YYYY.

Smoking Review

Do you currently smoke?

Do not currently smoke section

Have you smoked in the past?
How many cigarettes did you smoke in a day?

Do currently smoke section

How many cigarettes do you smoke in a day?
Would you like to give up smoking?

For help in giving up smoking please visit the Buzz website or book an appointment with our nurse.

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