Quiz – NRT

Quit Smoking Program
Pre-consultation Quiz

Please complete this short quiz to book in your initial consultation. It will only take 5 minutes and will help our doctors better understand your unique circumstances.

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Name
You will receive a confirmation to this email address.
Sex
Date Of Birth
Current Address
1. Each day, on average do you smoke:
2. After waking up, do you need a cigarette within:
3. How long have you been smoking for:
4. How many times have you tried quitting:
5. Have you tried NRT in the past?
6. Have you used doctor prescribed treatment in the past? If yes, what ave you been prescribed: *
11. Are you pregnant or breastfeeding?
12. Have you been diagnosed with any of the following?
Do you have a Medicare number or IHI?
Do you declare you are requesting NRT to reduce and eventually quit smoking?