Smoking/Alcohol Status - Stokewood Surgery

Name *

Date of Birth *

Please select your Smoking Status *

Current Smoker

Ex-smoker

Never Smoked

If you are a current smoker, please put the amount per day you Smoke.

Current Smokers: for Quitters Advice please call 0845 602 4663 *

I acknowledge the advice given.

I do not smoke (skip this question).

How often do you have a drink that contains alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many standard alcoholic drinks do you have on a typical day when you are drinking? *

I do not drink alcohol

1-2

3-4

5-6

7-9

10+

How often do you have 6 or more standard drinks on one occasion? *

Never

Less than monthly

Monthly

Weekly

Daily/almost daily

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, AND OTHER PERSONAL INFORMATION. THIS IS TO ALLOW THE PRACTICE TEAM 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.

Smoking & Alcohol Status

Smoking & Alcohol Status

Further Information

Cookies on the Stokewood Surgery website

Smoking & Alcohol Status

Smoking & Alcohol Status

Further Information