Disclaimer - Smoking Consultation

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?

What is your Date of Birth?

Day

Month

Year

Have you been diagnosed with any medical conditions? Yes | No

If Yes Give Details

Have you ever been diagnosed with a mental health illness? Yes | No

If Yes Give Details

Do you suffer from any allergies? Yes | No

If Yes Give Details

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines. Yes | No

If Yes Give Details

Are you currently using any medications/treatments to help you stop smoking?

Do you feel addicted to smoking?

How many years have you been smoking for?

How many cigarettes do you currently smoke per day?

What type of tobacco products do you use? (e.g., cigarettes, cigars, pipe, vaping)

Have you tried to quit smoking before?

How many times have you tried to quit smoking before?

What triggers your urge to smoke? (e.g. stress, social situations, after meals)

Do you smoke more at certain times of the day? If so, when?

On a scale of 1 to 10, how motivated are you to quit smoking?

Have you previously been prescribed pain relief medication for this condition?

What are your main reasons for wanting to quit? (e.g. health concerns, financial reasons, family influence)

Are you currently experiencing any smoking-related health issues? Yes | No

If Yes Please provide more information

I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform my own regular doctor of

Would you like us to inform your GP?

To continue, please provide your GP's surgery address below.

Product

Zyban (Bupropion)£29.99