Alcohol & Smoking Questionnaire

If you are unsure about alcohol limit and unit guidelines then please visit Drinkaware for further information.

Even if you have never smoked, please complete the following form so that we can update our records.

If you would like help to stop smoking, then please enquire at Reception about booking into our ‘Stop Smoking’ Clinic or read the information on the NHS website.

Your Details


Your Alcohol Data

Your Smoking Data

Have you Ever Smoked *  
I confirm that the information that I have provided is accurate to the best of my knowledge and that I will update the surgery if there are any changes to my health *  

How do we contact you?

Please confirm if you would be happy for the surgery to communicate with you by e-mail  
I would like to receive text reminders  
Fields marked with an asterisk (*) are mandatory