Male Patients - Application for Stop Smoking Treatment

Stop Smoking

It can be very difficult to quit smoking.
Most smokers experience the withdrawal symptoms as particularly challenging.
Quit smoking tablets help you overcome cravings and increase your chances of becoming an ex-smoker.
To place your order, fill in our brief medical questionnaire. For additional support and information please review our forum.

Dr. Jody is online now

  • Dr. Jody Shanahan-Prendergast


How long have you been smoking? *

How many cigarettes do you smoke? *

Do you smoke cigarettes when consuming alcohol? *

Have you attempted to give up smoking before? *

Which of the following methods have you tried to stop smoking? *

Have you used Champix tablets to stop smoking? *

By whom was the Champix tablets last prescribed for you? *

Have you had any side-effects from the Champix tablets? *

Have you had any outside support to help your stop smoking? *

What is your birth sex? *


Have you ever had a kidney problem? *

Have you ever been treated for any psychological problems (such as anxiety, panic attacks or reactive depression), or for psychiatric problems (such as, mania, bipolar disorder or schizophrenia)? *

Apart from the issues already mentioned, were you ever treated for any previous Accidents, Operations, Investigations or Illnesses? *

Can you tell us your current height (enter as centimetres)?

Can you tell us your current weight (enter as kg)?

Are you currently or in the last two months taking any medications (prescribed or not) or recreational drugs other than any medication you have mentioned in this consultation? *

Do you have any sensitivity to medicines or any allergies (e.g. Hay Fever, Animal Dander, Nuts etc)? *

I confirm that I have read and understood this and my answers are fully correct and true. *