Smoking Status

To help us update your patient records with your smoking status, please take a couple of minutes to fill in our smoking questionnaire.

Please complete the questionnaire whether you smoke, are an ex-smoker or a non-smoker.

Smoking Status

First Name

Surname

Date of Birth

Email Address

What is your Smoking Status?

When did you start? (mm/yyyy)

What do you smoke? (Cigars, Cigarettes, etc)

Would you like our assistance in helping you to stop smoking?

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.

I consent to my information being used for the purposes described above and wish to submit this online form to Braehead Medical Practice • Renfrew Health and Social Work Centre, 10 Ferry Road, Renfrew, PA4 8RU.

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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