Please take a couple of minutes to fill in our smoking questionnaire whether you smoke or not. This will enable us to quickly and easily update your patient records with your smoking status.

Smoking Questionnaire * = Required field First Names: * Last Name: Date of Birth (dd/mm/yyyy): Your Email Address: * Do you smoke? Yes No Have you ever smoked regularly? Yes No I smoke... (please enter amount in the appropriate box) Cigarettes / Cigars per day OR grams of tobacco per week Are you intending on quitting? Yes No Are you aware of the CAMQUIT Smoking Clinic on 01480 418693 and that you can also see one of the Practice Nurses or doctors to help you quit smoking. I accept the terms and conditions Please Click Here, to view the Terms & Conditions