Smoking Review Smoking Review Name * Date of Birth * Please use this date format: DD/MM/YYYY. Email address * By giving us your email address on this online form, we assume consent to reply to this form via email when necessary. If you prefer not to receive email, please contact the surgery by telephone. Phone number Do you have any communication/information needs relating to disability, impairment or sensory loss? Yes No Please be specific: What is your smoking status? * Smoker Ex-smoker Never smoked Do you want help to quit? Yes No Please contact LiveWell Dorset on 0800 8401 628 or http://www.livewelldorset.co.uk/index.html Please tell us when you quit.