Lung Cancer Screening Questionnaire
This questionnaire is designed to assess your eligibility and risk factors for lung cancer screening. Please answer all questions accurately to help determine the appropriate next steps for your care.
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Medical History
Have you ever been diagnosed with cancer?
Yes
No
If yes, please specify
Do you have any chronic lung diseases (e.g., COPD, emphysema)?
Yes
No
Have you had any recent chest imaging (X-ray, CT scan)?
Yes
No
If yes, please provide details
Smoking History
Have you ever smoked?
Yes
No
Do you currently smoke?
Yes
No
Age you started smoking
Age you quit (if applicable)
Average number of cigarettes per day
Total years of smoking
Symptoms
Do you have a persistent cough?
Yes
No
Have you experienced coughing up blood?
Yes
No
Do you have shortness of breath?
Yes
No
Unexplained weight loss?
Yes
No
Chest pain?
Yes
No
Family History
Family history of lung cancer?
Yes
No
If yes, relationship to affected person
Environmental & Occupational Exposure
Exposure to secondhand smoke
Yes
No
Exposure to asbestos, radon, or hazardous chemicals
Yes
No
Occupational exposure (e.g., mining, construction)
Yes
No
Please provide details (if applicable)
Eligibility & Risk Assessment
Have you previously undergone lung cancer screening?
Yes
No
Are you interested in screening services?
Yes
No
Consent & Declaration
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: