Smoking Review

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

Section

Smoking Review

Please specify: *

Do not currently smoke section

Please specify:
How many times did you use you E-Cigarette in a day?

Do currently smoke section

Do currently use e-cigarette section

How many times do you use you E-Cigarette in a day?
Would you like to give up E-Cigarettes?

Please ask at reception for more information about giving up.