Appointment Date _______________
CT LUNG SCREENING FORM
Patient Name ____________________________________________________
________ CLMA ________ Huntley
Age ______ DOB __________ (required) M or F
How many packs per day __________ x How many years have you smoked ____________ = Packs Years: ___________________
Current Smoker:
Yes
No
Quit year: _________
Inclusion Criteria:
Yes
Yes
Yes
No
No
No
Are you between the Ages of 55-80 years?
30 or more pack-years of cigarette smoking history (pack years = packs per day x years smoked)
Are you a former smoker having quit smoking within 15 years?
Exclusion Criteria: If you answer yes to any of the following please call 815-356-2395
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
Have you had a Chest CT examination in the past 18 months at a Centegra location?
Have you had pneumonia or acute respiratory infection treated with antibiotics in the prior 12 weeks?
Do you have history of lung cancer?
Do you have a history of removal of any portion of the lung, excluding needle biopsy?
Have you been diagnosed or treatment for any cancer other than non melanoma skin cancer or carcinoma in situ
(With the exception of transitional cell carcinoma in situ or bladder carcinoma in situ) in the previous 5 years?
Any unexplained weight loss of more than 15 pounds in the prior 12 months?
Are you experiencing coughing blood/recent hemoptysis?
Lung Nodules
Y
N
COPD/Emphysema Y
N
Pneumonia
Y
N
Chest Pain
Y
N
Hoarseness
Y
N
Respiratory Symptoms
Y
N
Family History Lung Cancer
Y
N
Tuberculosis
Y
N
Exposure to Radon/Asbestos Y
N
Past Medical History:
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Height ________
Weight _________
Allergies _______________________________________________________
Cell # ______________________ Home # ________________________ email: ________________________________________
Primary Care Physician ___________________________________________
CT Tech Signature ________________________________
Notes: ________________________________________________________________________________________________
Patient took Freshstart Folder
Patient refused Freshstart Folder
N/A