Sample, Sammy G ST0001

Lung Screening Intake Form 1234567890


The participant was identified as a potential lung screening candidate by:

Eligible based on chart review?


Was a pre-enrollment discussion held?

Pre-Enrollment Discussion

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A pre-enrollment discussion with the participant resulted in:


Intake discussion

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Smoking History

Form Reported Date Pack Years Cumulative

MM/DD/YYYY

Additional information can be provided on the background form

MM/DD/YYYY
Location if not in VA
MM/DD/YYYY
Location if not in VA


Candidate is of age and exposure to cigarette smoke as described above, and without a current diagnosis or obvious symptoms suggestive of lung cancer, has been educated today about the estimated risk for lung cancer, the possibility of a cure or life prolonging if an early lung cancer were to be found during screening, the possibility of imaging abnormalities not being lung cancer, the possibility of complications from additional diagnostic procedures, and the approximate amount of radiation exposure associated with each screening procedure. In addition, the candidate has been educated today about the importance of adhering to annual lung screening, the possible impact of other medical conditions on the overall health status, the importance of avoiding exposure to cigarette smoke, available tobacco cessation programs and available lung screening services at this facility. Education material was provided to the candidate.


Participant Communication Record

Free-form notes to track communications with the participant

Communication Log


      

Current Status


MM/DD/YYYY

Change Log