Stop SMoking Service

This questionnaire is designed to help you think about your smoking, and join the smoking cessation service provided by CMP

Last Updated: 10/03/2021

Information

The information collected in this questionnaire is strictly confidential and is held securely in line with the Data Protection Act (1998). The information in italics is required by the Department of Health and your Primary Care Trust for monitoring and evaluating our service – your advisor and the Primary Care Trust hold this information. The other information is held and used solely by clinical staff to guide your treatment and is not held by the West Sussex PCT. Any publication of data from the service will not identify individuals and information will only be used where it is strictly necessary to do so. Please discuss any concerns you may have with the advisor. Your Smoking Cessation Advisor may contact you 1 year after your quit date to follow up your progress, if you do not wish to do this please tick the box. (All maternal smokers will be followed up after one year). If you are successful in your quit attempt your GP practice will be notified so that your status as a former smoker can be recorded onto practice systems. If you do not wish us to tell your GP that you have stopped smoking please tick the box. You have the option not to share this information – if you wish to do so, please speak to your advisor. Signing below indicates that you have read this notice and agree to its terms.



Personal Details










About your Health










Tobacco Use








Previous Quit Attempts: