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Lifestyle Profile

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Darley Dale Surgery

Are you frustrated at the number of times you are asked about your smoking status and other lifestyle choices by the surgery?

If the answer is 'yes', we would be very grateful if you could complete the form below to update your smoking status online.

It is hoped that by introducing this page to our website, we will be able to keep better track of our patients' lifestyle profile, thereby reducing correspondence and unneccesary questions.

In time, we may add further sections to this form, but for now we are concentrating on your smoking status.

In order to process your request efficiently, we would ask that you complete all of the following information as accurately as possible.

When you click the 'Submit' button your surgery will be able to update your profile. Thank you for your time.

Please answer the following question(s) regarding your smoking status:
What is your smoking status?




In order for us to update your records, please complete the following personal details. Please be assured that these details will be held in the strictest confidence and only used to update your surgery records.
First Name
Surname
Date of Birth
eg 240272 (DDMMYY)
Home Postcode

We may wish to contact you by email/SMS in the future. If you would be happy for us to do so, please complete the following boxes.
E-mail Address
Mobile Phone Number
Enter with no spaces