Smoking Review Form If you have been invited by the practice to submit an asthma review, please complete this form. Smoking Review First Name * Last Name * Email * Date of birth * Please use format day/month/year e.g. 12/05/1979 Phone Number * Your Smoking Status Do you smoke? * Never smoked Ex smoker Light smoker 1-9/day Moderate smoker 10-19/day Heavy smoker 20-39/day Very heavy Smoker 40+/day Smoking Cessation Yes - I would like help to stop smoking No Thanks - not right now N/A I do not smoke If you smoke, giving up smoking is the single best thing you can do for your health. We can offer you support to cut down and quit. Please indicate if you would like us to contact you regarding support to stop smoking. Check and Send
