Your Consultation – mypharmacystop.com

What is your name ?

How long have you been smoking?

Less than one year

Between one and five years

More than five years

How many cigarettes do you smoke a day?

Have you attempted to give up smoking before?

Yes

Did you take part in a support programme?

Yes

Have you ever been diagnosed with a kidney condition?

Yes

Have you ever been diagnosed with a liver condition?

Yes

Have you ever had a mental health or psychiatric condition such as depression, anxiety, panic attacks, mania, bipolar disorder, schizophrenia or ADHD?

Yes

Have you ever had a stroke?

Yes

Do you have heart disease?

Yes

Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?

Yes

Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?

Yes

In the last two months have you taken any medicine, including both prescription and non-prescription medicines, other than any medicine you have mentioned above?

Yes

Are you allergic to any of the following?

Please select all that apply.

Do you have any other known allergies?

Yes

Stop Smoking