Medical and Smoking History Questionnarie

Personal Information

First name

Last name

Date of birth

Gender

Street Address

City/Town

Postcode

Country

Mobile number

Is Valide Number

Online Prescriptions for Vaping

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Medical History

Please list below any significant medical illnesses, such as diabetes, cancer, asthma, COPD/emphysema or psychiatric disorders.

Have you had a stroke, heart attack, irregular heartbeat, uncontrolled hypertension or angina in the past month?

Yes

Are you breastfeeding, pregnant, or planning to become pregnant within the next 12 months?

Yes

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Is there anything else you would like to mention before proceeding?

Complete abstinence from smoking and vaping is the safest option for your health. Nicotine is addictive, and the long-term risks of vaping are unknown. Currently no nicotine vaping products have been approved by the TGA, and the safety of these products has not yet been thoroughly assessed. Quit Clinics, or its doctors, cannot guarantee the safety of any vaping product. In order to minimise risk of harms, only short-term use of e-cigarettes is recommended, and dual use (vaping plus smoking) needs to be avoided.

I confirm that I have read and understand the above safety information

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