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Lung Cancer Screening Questionnaire

Clinics and physicians use this to judge whether a patient is a good candidate for lung cancer screening. It covers medical background, smoking history, current symptoms, family history and exposure to risky substances.

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Name

First Name

Last Name

Date of birth

Age

Phone number

Have you ever been diagnosed with cancer?

Yes No

If yes, please specify

Do you have any chronic lung disease (e.g., COPD, emphysema)?

Yes No

Have you had recent chest imaging (X-ray, CT scan)?

Yes No

If yes, please provide details

Have you ever smoked?

Yes No

Do you currently smoke?

Yes No

Age you started smoking

Age you quit (if applicable)

Average cigarettes per day

Total years of smoking

Do you have a persistent cough?

Yes No

Have you coughed up blood?

Yes No

Do you have shortness of breath?

Yes No

Unexplained weight loss?

Yes No

Chest pain?

Yes No

Family history of lung cancer?

Yes No

If yes, relationship to the affected person

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)

Have you had lung cancer screening before?

Yes No

Are you interested in screening services?

Yes No

Signature

Sign here

Date

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