Smoking Review About YouName First Name Surname Date of birth Day Month Year What is your Smoking Status? I am a current Smoker I used to smoke but have now given up I have never smoked Current SmokerWhen did you start Smoking? Day Month Year What and how often do you smoke?Provide as much information as you can about your smoking. Include details of what you smoke (Cigars, Cigarettes, Pipe etc) and how often.Would you like our assistance in helping you to stop smoking? Yes No Ex SmokerWhen did you start Smoking? Day Month Year When did you stop Smoking? Day Month Year Tell us more about your smoking historyProvide as much information as you can about your smoking. Include details of what you smoked (Cigars, Cigarettes, Pipe etc) and how often.PrivacyThis 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. The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible. We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. If you are not completely happy to provide information via the internet please contact the practice directly.Privacy Policy I consent to the practice collecting and storing my data from this form.