Quit Smoking Consultation Enquiry

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Quit Smoking Consultation Enquiry

Required*

Quit Smoking Consultation Enquiry

1 Personal Details

* Indicates required question

Date of Birth (mm/dd/yyyy)*

Gender*

Phone Number*

Residential Address (as per your Licence/Medicare Card)

Medicare Card Number* (required for E-Prescriptions)

Please include all 10 Numbers

Valid To / Expiry Date* (required for E-Prescriptions)

Pension/Health Care Card Number

Valid To / Expiry Date

Are you an Aboriginal and/or Torres Strait Islander

Email address*

2 Medical history

* Indicates required question

List any medical conditions (physical and/or mental health) For example: diabetes, hypertension, previous heart disease, depression.*

Allergies: (write n/a if not applicable)*

Regular medications: (write n/a if not applicable)*

3 Smoking history

* Indicates required question

Age when you started smoking:*

How many years have you smoked for?*

At your highest level of smoking, how many cigarettes (or tobacco) per day?*

How long could you wait in the morning, before needing to smoke? (eg immediately on waking/a few hours later)*

Did you try smoking cessation treatment before* (eg nicotine patches/gum/spray; Champix; other)

Patient Consent :

Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed. .By signing below, you are consenting to the collection of your personal information, and that it may be used or disclosed by the practice as per our Privacy Policy. I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed.

I agree

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