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Smoking Review

EG162

Are you completing this form on behalf of: 
First Name(s) 
First name as it appears on your/their passport
Last Name 
Last name as it appears on your/their passport
Postcode 
The one you/they have used to register with the GP practice
Date of birth 
The DOB is required to verify your/their identity
Sex 
As recorded in your/their medical record
Phone number 
The practice may use this number to contact you about your request
Do you/they currently smoke?
How many cigarettes do you/they smoke in a day
How many grams of tobacco per week?
Would you/they like to give up smoking?
Please confirm to proceed: 
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