Smoking Review Form

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The Chapel Medical Centre

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Upton Hospital, Albert Street, Slough, SL1 2BJ, 03000 24 0001

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Training Day Closed

Surgery Closed for Staff Training from 12.30 Tuesday 17th June 2025

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Smoking Review Form

If you have been advised by the surgery to submit a smoking review please use this form.

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Smoking Review

Do you currently smoke? *

Yes No

If 'Yes' How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

4 orr more

If 'No' Have you smoked in the past?

Yes No

IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9

10 to 19

20 to 39

40 or more

THIS 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. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 01 January 1900
Page created: 08 February 2019

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