2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3582 0000
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Stop Smoking Service

FREE STOP SMOKING SERVICE available at your GP practice.

QUIT TODAY AND SEE HOW MUCH YOU CAN SAVE!

Enter number of cigarettes smoked daily:
£0.00

(Annual saving based on cigarrette pack costing £10.00/20pack)

Patient Name
Date Of Birth
Contact Number
E-Mail Address
Address
What do you smoke?
Cigarettes per week
Roll Up Tobacco oz per week
Cigars per week
What age were you when you started smoking?
Which of the following do you have a family history of:

Cancer

IHD (Ischemic Heart Disease)

COPD (Chronic Obstructive Pulmonary Disease)

Are you happy to share your smoking data with NHS england to help them improve smoking services for other patients? Yes No
How soon after waking up do you have your first cigarette?
Have you previously attempted to stop smoking? No Yes
Click here to test for low/medium/high impact lung damage, related to your smoking.
Provide the score from the test:		 Low
Medium
High
Would you like to book an appointment with the practice pharmacist to quit smoking? No
Yes

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