Waddell Lung Screen Survey

Personal Information:











African American / Black
American Indian or Alaska Native
Asian
Hispanic or Latino
Other Race
White / Caucasian

Primary Care Physician:



Smoking Status Pack-Years



Have you had a prior CT of the chest in the last 12 months?




NCCN Lung Cancer Risk Factors for High Risk Qualification
Family history of lung cancer Personal history or chronic lung disease
   
Occupational exposure to lung carcinogens Radon exposure
 
   
Personal history of cancer (excluding known metastatic disease)