Smoking Review If you have been advised by the surgery to submit a smoking review on a regular basis please use this form. Name First Last Date of Birth Day Month Year PhoneEmail Enter Email Confirm Email Smoking ReviewDo you currently smoke? Yes No Have you smoked in the past? Yes No How many cigarettes do you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more How many cigarettes did you smoke in a day? 1 to 9 10 to 19 20 to 39 40 or more Would you like to give up smoking? Yes No Please ask at reception for more information about giving up smoking. I confirm that the information provided is accurate to the best of my knowledgePhone OptionalThis field is for validation purposes and should be left unchanged.