Smoking Review Name* First Last Date of Birth*Daytime telephone number*Email Smoking ReviewDo you currently smoke?* Yes No How many cigarettes do you smoke in a day?* 1-9 10-19 20-39 40 or more Have you ever smoked in the past?* Yes No How many cigarettes did you smoke in a day?* 1-9 10-19 20-39 40 or more Would you like help to give up smoking?* Yes No Consent* I agree that the information I supply when submitting this form may be used to update my medical records.