Stop Smoking Consultation

Personal Information & Smoking History

Please provide your details accurately

Name *

First

Last

Date of birth? *

YYYY

Phone number? *

Address? *

Email? *

For how long have you been smoking cigarettes? *

LESS THAN ONE YEAR BETWEEN ONE AND FIVE YEARS MORE THAN FIVE YEARS

How many cigarettes do you smoke everyday? *

Do you smoke cigarettes when you are drinking alcohol? *

NO YES

Have you tried to quit smoking recently or in the past? *

NO, I HAVE NEVER ATTEMPTED YES, I HAVE TRIED

What attempts have you tried to quit smoking? *

Select all that apply

NO, I HAVE NEVER ATTEMPTED NICOTINE REPLACEMENT (GUM/PATCHES/LOZENGES) ACUPUNCTURE WILLPOWER HYPNOTHERAPY ZYBAN (BUPROPION) OTHER

If OTHER, please specify:

What methods have you used before to quit smoking? *

NO, I'VE NOT YES, I HAVE

Please specify:

Has any healthcare provider prescribed you Champix tablets for you? *

NEVER PRESCRIBED CHAMPIX DOCTOR ONLINE DOCTOR PHARMACY OTHER

If OTHER, please specify:

Did you notice any side-effect when you were using Champix tablets?

NEVER PRESCRIBED CHAMPIX NO, I'VE NOT YES, I HAVE

If YES, I HAVE, please specify:

Have you ever used any other support to quit smoking? *

NO, I'VE NOT YES, I HAVE

If YES, I HAVE, please specify (support group/family/other):

Please specify your gender? *

MALE FEMALE

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Medical History

Please provide details about your health

Do you have any underlying liver or kidney disease? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Do you have any medical history of psychological or psychiatric issues (eg, Anxiety, panic attacks, depression, mania, bipolar disorder or schizophrenia)? *

NO YES, I HAVE

If YES, I HAVE, please specify details when this occurred, what was the cause and are you currently on any treatment for the condition:

Do you have any past medical history or past surgical history that you want to mention to our doctor? *

NO YES, I WAS

If YES, I WAS, please specify:

Have you used any prescription, non-prescription based medication or any illegal drugs or herbal medications in the last 2 months? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Are you allergic to any medication or any substance? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Please specify the name of preferred pharmacy where you want to collect your prescription/medications? *

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge. *

I CONFIRM I DO NOT CONFIRM

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Review your details and complete payment

Consultation Summary

Stop Smoking Consultation Fee

GP Review + Prescription

€25.00

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