Dorset SmokesStop

Online Support

If you are thinking of giving up smoking but it is currently inconvenient for you to contact us, complete the form below giving as much information as possible and we will get back to you with details of support in your area.

If you have any questions about the service or would like to find out about groups near you please email us.

 

Your Details

Email address:
Name:
Address:
 
 
Postcode:
Telephone:
Date of birth:
Gender:
Male
 

Your Motivation
How many cigarettes do you smoke per day?
How soon after waking do you smoke?
What is your primary reason for giving up?
How keen are you to give up smoking?
Please rate between 1 and 5 (1 being the lowest)
 

Previous attempts to give up
Please mark the following either yes or no:
I have tried before:
How many times have you tried to give up
When I tried before I did so without help:
If you have tried to give up before what did you use?
How long have you been smoking?
years
Are you pregnant?
Are you under 16?

What is your job title?
Where did you hear about the smokestop service:
Today's date

Comments

please indicate if you are pregnant or are interested in quitting within your workplace