Smoking Review Form Smoking Review Form If you have been advised by the surgery to a submit smoking review please use this form. Name First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone OptionalEmail Address Smoking ReviewDo you currently smoke? Yes Optional No Optional If 'Yes' How many cigarettes do you smoke in a day? 1 to 9 Optional 10 to 19 Optional 20 to 39 Optional 40 or more Optional If 'No' Have you smoked in the past? 1 to 9 Optional 10 to 19 Optional 20 to 39 Optional 40 or more Optional Consent I consent to the practice collecting and storing my data from this form. OptionalTHIS 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.