Smoking Review Form

Date of Birth *

MM

DD

YYYY

Do you currently smoke?

Yes

No

Are you an ex-smoker?

Yes

No

If you're an ex-smoker, when did you quit?

MM

DD

YYYY

What tobacco products do/did you use?

Cigarettes

Self-Rolled tobacco

Cigars

Pipe

e-Cigarette / Vape

Other (please specify below)

Privacy Policy *

This form collects your name, date of birth, email, other personal information and medical details which you enter. We use Squarespace as our website provider and any information you enter into this form is also processed by them in accordance with GDPR and forwarded to Severn Valley Medical Practice's NHS email address. 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.

I consent to the practice collecting and storing my data from this form.