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NHS Direct Wales - 0845 46 47 - Galw IECHYD Cymru
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Smoking Questionnaire

Please take a couple of minutes to fill in our smoking questionnaire whether you smoke or not. This will enable us to quickly and easily update your patient records with your smoking status.

Smoking Questionnaire

Please enter amount in the appropriate box:

Cigarettes / Cigars per day OR
grams of tobacco per week

Are you aware that you can speak to GP or a pharmacist to help you quit smoking?

They will contact you and offer free advice and support

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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