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Peterhead Health Centre
Menu
Home
About Us
Contact Us
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Training Practice
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
NHS Inform – Symptoms and Self-Help
Referral for Further Care
See a Doctor or Healthcare Professional
Self Referral Services
Tests & Investigations
Clinics
Antenatal Care
Child Health Checks
Our Clinics
Long Term Conditions
Hospital Discharge Arrangements
Practice Services
Repeat Prescriptions
Travel Clinic
Register with us as a New Patient
Sick Note
Forms
Keep us up to Date
Electronic Reviews
New Patient Registration
Help & Support
News
Peterhead Health Centre
>
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Electronic Reviews
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Smoking Review Form
Smoking Review Form
Smoking Review
First Name
*
Last Name
*
Email
*
Enter Email
Date of birth
*
Please use format day/month/year e.g. 12/05/1979
Phone Number
*
Your Smoking Status
Do you currently smoke?
*
Yes
No
How many cigarettes do you smoke each day?
1 to 9
10 to 19
20 to 39
40 or more
Would you like to give up smoking?
Yes
No
Did you smoke in the past?
*
Yes
No
How many cigarettes did you smoke each day when you were a smoker?
1 to 9
10 to 19
20 to 39
40 or more
Privacy Policy
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.
*
I consent to the practice collecting and storing my data from this form.
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Home
About Us
Contact Us
Have your Say
Making the most of your Practice
Meet the Team
Doctors
Nurses
Practice Team
Our Allied Health Professionals
Opening Hours
What to do when we are closed
Practice Policies
At the Practice
Data
Patient Record
Patient Rights
Website
Training Practice
Teenage Friendly
Clinics & Services
Appointments, Tests & Referrals
Appointments
NHS Inform – Symptoms and Self-Help
Referral for Further Care
See a Doctor or Healthcare Professional
Self Referral Services
Tests & Investigations
Clinics
Antenatal Care
Child Health Checks
Our Clinics
Long Term Conditions
Hospital Discharge Arrangements
Practice Services
Repeat Prescriptions
Travel Clinic
Register with us as a New Patient
Sick Note
Forms
Keep us up to Date
Electronic Reviews
New Patient Registration
Help & Support
News