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OTHER INFORMATION A to Z

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Smoking Review Form - Brim

Smoking Review Form - Brim

Smoking Review Form - Brim

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

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Smoking Review

Do you currently smoke? *

Yes No

If 'Yes' How many cigarettes 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 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9

10 to 19

20 to 39

40 or more

IF YOU SMOKE WOULD YOU LIKE CESSATION ADVICE?

Yes No

THIS LINK WILL DIRECT YOU TO STOP SMOKING SERVICES

https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/

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.

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Page last reviewed: 06 May 2020
Page created: 20 April 2020

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