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Quit Master UK First Name Family Name (surname) Age Sex Male Female Marital status Home Telephone Marital Status-single Married Divorced Mobile Telephone Address 1 City County Post Code (Zip) Email Address Profession Medical Information - This information helps us gain a better understanding on how to treat YOU! Are you currently taking any medication? (Please list) Are currently under the care of a Doctor? It is standard procedure for us to notifyyour Doctor about this cessation programme, is this OK? If Yes, please provide Doctor's Name and Surgery Name Did your Doctor recommend that you stop smoking? Current Smoking details? How many cigarettes do you smoke a day? When did you startsmoking and why? What methods (if any)have you used to try tostop smoking? General Who referred you/How did you hear about us?

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