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Smoking Questionnaire

First Name *

Surname *

Email *

Date of Birth *

Day

Month

Year

Smoking Status: *

I don't smoke
I smoke and would like a referral to free stop smoking support
I smoke but don't want help right now

Are you completing this on behalf of someone else? *

Your name and relationship to patient *

Declaration *

I confirm that I am the patient named above, or I am authorized to provide this information on their behalf (for example, I hold an activated Enduring Power of Attorney for personal care and welfare, I am their welfare guardian, I am the parent or guardian of a child patient, or the patient has given me permission).

I understand that the information I provide will be added to the patient’s health record at [Practice name] and used by the health team to support their care, in line with the Health Information Privacy Code 2020.

I confirm that the information is accurate to the best of my knowledge.