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Health @ Tuxford NHS GP Surgery in Newark

Smoking review

Smoking Review

Section

Smoking Review

Do you currently smoke? *

Yes

Do not currently smoke section

Have you smoked in the past? *

Yes

Please select all that apply:

Cigarettes

Cigars

Rollups

Pipe

E Cigarettes

How many cigarettes did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars did you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco did you smoke per week? *

Pipe – How many grams of tobacco did you smoke per week? *

Do currently smoke section

Please select all that apply:

Cigarettes

Cigars

Rollups

Pipe

E Cigarettes

How many cigarettes do you smoke in a day? *

1 to 9

10 to 19

20 to 39

40 or more

How many cigars do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Rollups – How many grams of tobacco do you smoke per week?

Pipe – How many grams of tobacco do you smoke per week?

Would you like to give up smoking? *

Yes

Please ask at reception for more information about giving up smoking.

I confirm that the information provided is accurate to the best of my knowledge

If you are human, leave this field blank.

Tuxford Medical Centre
Faraday Avenue
Tuxford
Newark
NG22 0HT

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01777 870203

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