Self-Assessment for Lung Cancer Screening

Self-Assessment for Lung Cancer

This form will take about a minute for completion
How old are you*

Less than 50 years old50 - 60 years old60 - 70 years old70 - 80 years oldOlder than 80 years old
What is your smoking status?*

Never smokedCurrently smokingHave quit smoking
If you are currently smoking, how many packs do you smoke a day?

Half a packThree quarters of a pack1 pack1.5 packs2 packs3 packs4 packs
How many years have you been smoking?
Based on the above response, this is the number of pack-years you are smoking.
How long have you quit smoking

Less than 15 years agoMore than 15 years ago
Prior to quitting, how many packs did you smoke a day?

Half a packThree quarters of a pack1 pack1.5 packs2 packs3 packs4 packs and more
How many years did you smoke for?
Based on the above response, this is the number of pack years you have smoked.
Depending on your responses above, a number 20 and above indicates that you are at high-risk for lung cancer and should speak to a doctor for a more thorough assessment and recommendation.
Auto-calculated field
Depending on your responses above, a number 20 and above indicates that you are at high-risk for lung cancer and should speak to a doctor for a more thorough assessment and recommendation.
Auto-calculated field for former smokers
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