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Springfield Medical Centre NHS GP Surgery in Eccles

Smoking review

Smoking Review

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Confirmation of consent for information about your/the patient’s health to be sent to the email address provided

Smoking Review

Do you currently smoke?

Yes

Do not currently smoke section

Have you smoked in the past?

Yes

How many cigarettes did you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Do currently smoke section

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to give up smoking?

Yes

Please ask at reception for more information about giving up smoking.

I confirm that the information provided is accurate to the best of my knowledge

If you are human, leave this field blank.

This form has been turned off. It will be turned on again when the practice re-opens

To get the healthcare support you may need, please call us on 0161 871 2450, speak to your local pharmacist or contact NHS 111. You can also visit our online Treatment Room for self-help information on physical health requests or our online Wellbeing Centre for information about mental health services, including crisis support.

384 Liverpool Road
Eccles
Manchester
M30 8QD

Get directions

0161 871 2450