Smoking & Alcohol Status

Last Updated: 02/09/2022

Patient Details

Name *

Date of Birth *

Smoking Status

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).

Alcohol Status

Disclaimer

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.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Stokewood Surgery website

Smoking & Alcohol Status

Further Information