Lung Cancer Screening Form

Male    Female

Current Smoker
Former Smoker
Never Smoker

Do you have any of the following medical conditions?
(check all the apply)

COPD
Pulmonary Fibrosis
Emphysema
Coronary Artery Disease
Lung Cancer
Peripheral Vascular Disease

Cancer related history?

Prior history of lung cancer
Lymphoma
Head/Neck Cancer
Bladder Cancer
Esophageal Cancer
Pulmonary Fibrosis
Other Cancer

Have you had exposure to any of the following carcinogens?

Silica
Cadmium
Asbestos
Arsenic
Beryllium
Chromium
Diesel Fumes
Nickel
Yes
No
Do you have a first-degree family history of lung cancer (mother, father, sister, brother, daughter or son with history of lung cancer)?
Family history of lung cancer other than first-degree relative?
Second hand smoke exposure?

Do you have any signs or symptoms of lung cancer?