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Central Medical Centre NHS GP Surgery in Merton

Smoking review

Smoking Review

Section

Please specify the ethnic group the patient belongs to: *

Please specify: *

Smoking status: *

Never smoked

Ex-smoker

Current smoker

Smoker

When did you start smoking?

What do you mainly smoke (select all that apply)?

Cigarette smoker

Pipe smoker

Rolls own cigarettes

Cigar smoker

Cigarettes – Number per day:

Please select one of the following:

Trivial cigarette smoker (less than one cigarette/day)

Light cigarette smoker (1-9 cigs/day)

Moderate cigarette smoker (10-19 cigs/day)

Heavy cigarette smoker (20-39 cigs/day)

Very heavy cigarette smoker (40+ cigs/day)

Pipe – Grams per week:

Rollups – Grams per week:

Cigars – Number per day:

Would you like to give up smoking?

Yes

Please ask at reception for more information about giving up smoking.

Ex-smoker

When did you quit smoking?

What did you mainly smoke (select all that apply)?

Cigarette smoker

Pipe smoker

Rolls own cigarettes

Cigar smoker

Cigarettes – Number per day:

Please select one of the following:

Trivial cigarette smoker (less than one cigarette/day)

Light cigarette smoker (1-9 cigs/day)

Moderate cigarette smoker (10-19 cigs/day)

Heavy cigarette smoker (20-39 cigs/day)

Very heavy cigarette smoker (40+ cigs/day)

Pipe – Grams per week:

Rollups – Grams per week:

Cigars – Number per day:

I confirm that the information provided is accurate to the best of my knowledge

If you are human, leave this field blank.

42 – 46 Central Road
Morden
Surrey
SM4 5RT

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0208 648 9126

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