Lung Cancer Risk Assessment Questionnaire Form
Please complete the Lung Cancer Risk Assessment Questionnaire Form to help evaluate potential risk factors. All responses are confidential and used solely for general risk awareness.
What is your age group?
*
Under 40
40-49
50-59
60-69
70 or older
What is your gender?
*
Male
Female
Prefer not to say
Other
Have you ever smoked tobacco products?
*
Never
Former smoker
Current smoker
If you have smoked, for how many years?
*
Not applicable
Less than 10 years
10-19 years
20-29 years
30 years or more
Have you been regularly exposed to secondhand smoke?
*
Yes, currently
Yes, in the past
No
Do you have a family history of lung cancer?
*
Yes
No
Not sure
Please rate your current exposure to environmental risk factors (e.g., asbestos, radon, industrial chemicals):
*
1
2
3
4
5
How often do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Persistent cough
1
2
3
4
5
Shortness of breath
6
7
8
9
10
Chest pain
11
12
13
14
15
Coughing up blood
16
17
18
19
20
How would you rate your overall lung health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Have you ever worked in an occupation with increased risk of lung cancer (e.g., mining, construction, manufacturing)?
*
Yes, currently
Yes, in the past
No
Submit
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