Smoking Questionnaire

Name *

Date of Birth *

Smoking Questionnaire

Do you smoke? *

Yes

No

Ex-smoker

Amount per day *

Would you like help with regards to stopping Smoking? *

Yes

No

Not at the moment

If yes, Please contact Lorraine Miller on telephone: 01454 412599

If you are interested in stopping smoking and want to know more contact Tracey Baillie Tel:01454 412599.