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 Please enter your full legal nameDate of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please enter in the format DD/MM/YYYYPhone Number OptionalEmail Address Smoking ReviewPlease complete the form belowDo you currently smoke? Yes No 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? Yes Optional No Optional Consent I consent to the practice collecting and storing my data from this form.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.