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Sample, Sammy G
ST0001
Followup Form
1234567890
This interaction is a
Other communication
CT visit and/or communication about CT results
Form date
MM/DD/YYYY
Date of baseline CT
MM/DD/YYYY
Coordinator
Time since baseline:
0
months
New CT follow-up date if needed
MM/DD/YYYY
Ordering Information
Reason for CT scan
Reason for CT scan
Have you taken antibiotics since your last CT scan?
Have you taken antibiotics since your last CT scan?
No
Yes
Is this an annual CT scan?
Is this an annual CT scan?
No
Yes
During the past year, have you experienced any of these symptoms?
During the past year, have you experienced any of these symptoms?
Cough producing bloody material
Unexplained weight loss greater than 20 lbs
Unexplained hoarseness
Other
Other
If yes, have you seen a physician for this?
If yes, have you seen a physician for this?
No
Yes
Whom?
If yes, are you now experiencing them?
If yes, are you now experiencing them?
No
Yes
When did you most recently have a chest CT?
When did you most recently have a chest CT?
-
Less than 6 months ago
6 months to 18 months ago
18 months to 3 years ago
3 years to 5 years ago
Over 5 years ago
Never
Have you been hospitalized in the past year?
Have you been hospitalized in the past year?
No
Yes
For what?
When?
Where?
Have you had a diagnosis of cancer in the past year?
Have you had a diagnosis of cancer in the past year?
No
Yes
What part of the body?
-
Breast
Colon / rectum
Liver
Lung / bronchus
Ovary
Pancreas
Prostate
Skin
Stomach
Uterus
Other (specify)
Other?
When were you diagnosed?
MM/DD/YYYY
If lung cancer has been diagnosed, have you had surgery?
If lung cancer has been diagnosed, have you had surgery?
No
Yes
N/A
When?
MM/DD/YYYY
Where?
If a lung cancer has been removed, is there evidence of recurrence?
If a lung cancer has been removed, is there evidence of recurrence?
No
Yes
N/A
Describe
Smoking History
Form
Reported Date
Pack Years
Cumulative
Since your last follow-up, have you smoked cigarettes at all, even a puff?
Since your last follow-up, have you smoked cigarettes at all, even a puff?
No
Yes
Never smoked
On average, how many cigarettes did you smoke per day?
On average, how many cigarettes did you smoke per day?
Quit Date
Quit Date
MM/DD/YYYY
How many
packs
of cigarettes did you smoke per day (PPD)?
How many
packs
of cigarettes did you smoke per day (PPD)?
Reported pack years
Reported pack years
Since we last asked, have you ever tried to quit smoking?
Since we last asked, have you ever tried to quit smoking?
No
Yes
N/A
How many times have you quit smoking for at least 24 hours?
How many times have you quit smoking for at least 24 hours?
Since we last asked what, if any, smoking cessation methods have you used?
Since we last asked what, if any, smoking cessation methods have you used?
Have not tried to quit
"Cold Turkey" by completely stopping on your own with no other assistance
Tapering or reducing number of cigarettes smoked per day
Self-help material (e.g., brochure, cessation website)
Individual consultation or cessation counseling
Telephone cessation counseling hotline
Peer support (e.g., Nicotine Anonymous)
Nicotine replacement therapy (e.g., patch, gum, inhaler, nasal spray, lozenge)
Zyban
Hypnosis
Acupuncture / acupressure
Other (specify)
Other
Are you seriously thinking of quitting smoking?
Are you seriously thinking of quitting smoking?
-
Yes, within the next 30 days
Yes, within the next 6 months
No, not thinking of quitting
N/A
Tobacco cessation provided:
Tobacco cessation provided:
Declined
Advised to quit smoking; resources provided
Interested in tobacco cessation medication. Encouraged to talk to provider or pharmacist about which medication option is best for you.
Communications method:
Communications method:
In person
Telephone
TeleHealth
Mailed letter
Message in Patient Portal
Video-on-Demand (VOD)
Other
Other contact method
Additional details
Communication about results
Last CT date
Last CT date
MM/DD/YYYY
Communications method:
Communications method:
In person
Telephone
TeleHealth
Mailed letter
Message in Patient Portal
Video-on-Demand (VOD)
Other
Other contact method
Additional details
Has a new CT/LDCT been ordered?
Has a new CT/LDCT been ordered?
No
Yes
Communication to pulmonary?
Communication to pulmonary?
No
Yes
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