Adelaide Medical Centre - London

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NHS 11 British Sign Language (BSL) Service for less urgent than 999 calls.
Cancer Support Guide
Patient Participation Group

Home
Home
Opening Hours
Online Services
Our Staff
Practice News
Contact Us
Language

Self Referrals & RFH Referral Portal
Our Surgery
Prescription & Services
Appointments
New Patients
Patient Administration Services & Enquiries
Health Advice / Online Forms
NHS 11 British Sign Language (BSL) Service for less urgent than 999 calls.
Cancer Support Guide
Patient Participation Group

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Smoking Review Form

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

Last Updated: 17/10/2022

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

40 or 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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