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Sample, Sammy G
ST0001
Background
1234567890
Self-report of Comorbidities and Exposures
Have you ever worked in any of the following?
Agent orange
Asbestos product manufacturing
Auto repair
Building maintenance
Burn pits
Chemical industry/foundry/refinery
Construction/demolition
Mining
Nuclear industry
Ship construction/repair
Other
Other work
Have you experienced any symptoms indicative of lung cancer?
No
Yes
Check all that apply
Cough producing bloody material
Unexplained weight loss greater than 20 lbs.
Unexplained hoarseness
Other
Other symptom
When did you most recently have a chest CT?
—
Less than 6 months ago
6–18 months ago
18 months to 3 years ago
3 years to 5 years ago
Over 5 years ago
Never
Where was the test done?
Have you had a pulmonary function test within the last five years?
No
Yes
FEV1 (L/s)
FVC (L)
Diffusion capacity (mL/min/mm Hg)
FEV1/FVC (%) is
If you currently smoke, how many times have you attempted to quit in the last 12 months?
Have you been provided with smoking cessation services?
No
Yes
When?
MM/DD/YYYY
Have you used any of the following medications?
Check all that apply
Varenicline
Buproprion
Patch
Lozenges
Gum
Other
Other medication
Have you been counseled on the 5 A’s (Ask, Assess, Advise, Assist, Arrange)?
No
Yes
Have you been referred for smoking cessation services?
No
Yes
Do you know if you have had any of the following?
Cancers
Family history of lung cancer
Family history of lung cancer
No
Yes
?
Father?
No
Yes
Mother?
No
Yes
Siblings?
No
Yes
Lung cancer
Lung cancer
No
Yes
?
Year
Melanoma
Melanoma
No
Yes
?
Year
Basal/squamous-cell skin cancer
Basal/squamous-cell skin cancer
No
Yes
?
Year
Leukemia
Leukemia
No
Yes
?
Year
Lymphoma
Lymphoma
No
Yes
?
Year
Any other cancer
Any other cancer
No
Yes
?
Specify
Year
Primary site
Pulmonary Problems
Asthma
Asthma
No
Yes
?
Under current treatment?
No
Yes
COPD/Emphysema/Chronic bronchitis
COPD/Emphysema/Chronic bronchitis
No
Yes
?
Year
Childhood pneumonia
Childhood pneumonia
No
Yes
?
Cardiac Diseases
Myocardial Infarction (MI)
Myocardial Infarction (MI)
No
Yes
?
Year
Where treated
Angiostents
Angiostents
No
Yes
?
Year
Where treated
CABG
CABG
No
Yes
?
Year
Where treated
Angina
Angina
No
Yes
?
Year
Where treated
Heart failure
Heart failure
No
Yes
?
Year
Where treated
High cholesterol
High cholesterol
No
Yes
?
Vascular Diseases
Stroke
Stroke
No
Yes
?
Year
Peripheral vascular disease
Peripheral vascular disease
No
Yes
?
Year
Hypertension
Hypertension
No
Yes
?
Treated?
No
Yes
Year
Highest value
Other Diseases
Diabetes
Diabetes
No
Yes
?
Starting at what age?
Treated?
No
Yes
Connective tissue diseases
Connective tissue diseases
No
Yes
?
Specify
Ulcer
Ulcer
No
Yes
?
Liver disease
Liver disease
No
Yes
?
Renal disease
Renal disease
No
Yes
?
Other
Other
No
Yes
?
Specify
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