Stop Smoking - WePrescribe

Stop Smoking Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Why are you requesting treatment today?

How long have you been smoking?

Over 6 months

Between 3 to 6 months

Less than 3 months

How many cigarettes do you smoke per day? (on average)

Less than 10 per day

More than 10 per day

How long after waking up (on average) would you have your first cigarette?

Within 1 hour

More than 1 hour

Have you ever previously tried to quit smoking?

Have you ever previously tried a treatment to stop smoking?

If so, please provide more information

Please provide more details

Have you ever previously experienced any of the following?

- Any kidney issues including decline in kidney function - A history of any heart conditions- this includes any previous heart attacks, strokes, high blood pressure or any heart rhythm conditions - Any history of seizures or epilepsy - Any mental health issues- even if stable on treatment (e.g. depression, anxiety, Bipolar, schizophrenia) - Any alcohol or drug dependency

Have you ever previously been diagnosed with any other medical conditions?

This includes conditions such as - Asthma - Kidney disease - Liver disease - Eczema

Please provide more details

Do you suffer with any allergies?

If so, please provide more information

Please provide more details

Do you currently take any medication? This includes herbal remedies and over the counter medication.

If so, please provide more information

Please provide more details

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Is there any other information you would like to share with our prescribing team?

If so, please provide more information

Please provide more details

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

Stop Smoking Consultation

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