Smoking Questionnaire Smoking Questionnaire Name First Last Date of Birth DD dash MM dash YYYY Telephone NumberDo you smoke? Yes No How many cigarettes do you smoke in a day?Would you like to give up smoking? Yes No Have you smoked in the past? Yes No Do you live in a household with smokers? Yes No Do you use an e-cigarette or vape? Yes No Do you smoke cannabis? Yes No If you would like help to stop smoking, please visit a local pharmacy who can offer assistance with this service, or contact NHS Lothian Quit Your Way on 0131 286 5113 or send an email to QuitYourWayServiceNHSLothian@nhslothian.scot.nhs.uk
