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Adelaide Street Family Practice

Do you smoke?

As our patient, we’re interested to know whether you smoke or not. Once we know this, we can offer you the right level of support.

Do you smoke?

1. Your details

Name *

Date of Birth (DD/MM/YY) *

Phone

Email

Do you currently smoke?

Yes (go to section 2)

No (go to section 3)

2. Smoking

2a. What do you smoke? (tick all that apply)

Cigarettes, pre-rolled (go to 2b)

Loose tobacco, rolling your own cigarettes or in a pipe (go to 2c)

Electronic cigarette

2b. How many cigarettes do you smoke a day?

Less than 1

1-9

10-19

20-39

40+

2c. How many grams of tobacco do you smoke a day?

2c (i). Do you roll your own cigarettes or smoke a pipe?

Roll my own cigarettes

Smoke a pipe

Would you like support in quitting smoking?

Yes

Not right now

No

3. Non-smoking

3a. Please tick the most relevant option:

Ex-smoker (no longer smoke at all)

Currently not smoking (likely to smoke again)

Never smoked tobacco

3b. Does anyone in your household smoke around you? (Passive smoking)

Yes

No

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