Must Stop Smoking
   
 
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MSS Questionnaire
 
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Must Stop Smoking Questionnaire
Please take 5 minutes to fill in this Questionaire when you book an appointment with Must Stop Smoking - you can call us on 01488 644 699

All Questions with a Star next to them are Required fields.

Title
required field
First Name
required field
Surname
required field
Address
required field
Address Line 2
Address Line 3
Town / City
required field
County / State
required field
Postcode
required field
Country
Email Address
required field
Contact Telephone Number
required field
Your Details
Age
required field
Gender
Male Female required field
Occupation
required field
Please tell us your History of Smoking below
Began
required field
How many a day?
required field
Why you began
required field
Previous attempts to stop
required field
Your Medical History
Past Medical History
Hospitalisations
Please List ANY Medications you are taking or have recently been taking
Allergies - Please list any allergies that you have
Family History
Any smokers in your family? (Parents / Siblings)
Home Situation
Status
Alone Partner Married Divorced Widowed required field
Do you have Stairs to climb?
Stairs No Stairs required field
Systems Check - Please TICK any that apply to you

Cardiovascular
Chest Pain
Breathlessness
Ankle Swelling
Palpitations
High Blood Pressure
Respiratory
Cough
Coughing Blood
Mucous
If you have mucous, please state what colour
Gastrointestinal
Appetite Change
Weight Change
Vomiting blood
Bowel Habit Change
Blood / Mucous Rectally
Genitourinary
Frequency
Nocturia
Blood in urine
Kidney or bladder stones
Colic
Stream Strength
Prolapse
Central Nervous System
Faints
Fits
Dizziness
Eyesight Problems
Hearing Problems
General Questions
Are you Pregnant?
Yes No Not Applicable required field
Are you Planning a Pregnancy?
Yes No Not Applicable required field
Have you been trying to conceive unsuccessfully?
Yes No Not Applicable
Do you take regular excercise?
How much Alcohol do you consume per week?
required field
How much Tea or Coffee do you drink per day
required field
How many spoons of Sugar do you have a day (in tea, coffee, cereal etc..)?
required field
Do you have cravings for alcohol, sweets or other foods?
required field
How many glasses of Water do you drink per day?
required field
Do you get Stressed?

Think of three very positive moments in your life and bring these memories with you!

Please now Submit the Form using the button below
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