Stop Smoking Form – Gees Chemist

Stop Smoking Questionnaire (#5)

First Name

Surname

Date Of Birth

NHS Number

Mobile Number

Address Line 1

Address Line 2

City

Postcode

1. How many cigarettes do you usually smoke each day?

2. How soon after waking do you smoke your first cigarette?

3. Which tobacco or nicotine products do you currently use?

Cigarettes

Hand-rolled tobacco

Cigars or pipe tobacco

Vape or e-cigarette

Other tobacco or nicotine product

4. Please tell us the best times to contact you

I confirm the information provided is accurate.

I do consent to assessment and GP notification where appropriate.

I understand this questionnaire must be reviewed before my appointment request can be accepted.

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