Smoking Status and Cessation Support

Ask:

Current status:

Date last smoked:
Recall in:
Cigarettes/day:
Note:
Currently pregnant:
Please provide active cessation management and follow-up. Notify LMC in referral document.

Brief Advice

Given today:     

Cessation Support Given Today









Referred to stop smoking service:




Referral:


Resources:

Claim



(Assumes consent given)