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Mountsandel Medical Centre

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AGHADOWEY SURGERY

We will be closed Wednesday the 1st January and will reopen as normal on Thursday 2nd at 8.30am OUR AGHADOWEY SURGERY CLOSES ON 20TH DECEMBER 2024. WE WILL CONTINUE TO PROVIDE CARE TO O

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Smoking Review Form

If you have been advised by the surgery to a submit smoking review please use this form.

Last Updated: 30/06/2024

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Smoking Review

Do you currently smoke? *

Yes No

Do you vape? *

Yes No

If 'Yes' How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

If 'No' Have you smoked in the past?

Yes No

IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9

10 to 19

20 to 39

40 or more

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. *

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