Smoking review

Do you currently smoke?

Yes

No

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

Cigarettes per day:

Tobacco per day:

Do you use an electronic cigarette / vaping?

Yes

No

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.

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