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Telephone: +44 (0) 203 176 0023

Questions Related to Quit Smoking

In order to prescribe treatments for Quit smoking our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.


How long have you been a smoker?

Why do you want to quit smoking?

Have you tried to quit smoking before, if so how?

Could there be any chance that you may be pregnant?

Are you currently breastfeeding?

Do you have epilepsy?

Do you have history of any psychiatric illness including depression?

How many do you smoke a day?

Are you taking insulin, warfarin, theophylline?

Do you suffer from sever renal impairment (kidney problems) or do you get dialysis?

Are you currently taking, doing or using anything to help you stop smoking?

Please confirm that you are aware that treatment with Champix should be stopped if agitation, depressed mood or changes in behaviour are causing concern