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Beauchamp House Surgery

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Patient Participation Group

NHS App
PATCHS
Fit Notes and Progesterone Only Pill Requests
Appointments
Latest Practice News
Prescriptions
Join the Practice
Services
Health Information
Test Results
GetUBetter
Contact Us
Chelmsford City Health PCN Limited
Patient Participation Group

Home
Language
Self Help and Local Support Services
Online Services
Opening Times and Out of Hours
Carers Support
About Us
Our Staff
Compliments and Complaints
Practice Policies
Chelmsford City Health PCN Limited

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Smoking Review Form

If you have been advised by the surgery to a submit smoking review please use this form.

Last Updated: 16/09/2024

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Smoking Review

Do you currently smoke? *

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If 'Yes' How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

If 'No' Have you smoked in the past?

Yes No

IF 'YES' HOW MANY CIGARETTES DID YOU SMOKE IN A DAY?

1 to 9

10 to 19

20 to 39

40 or more

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. *

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