Evaluating Your Lung Cancer Screening Eligibility

This confidential assessment can help you better understand whether you qualify for a lung cancer screening. While it can’t replace an evaluation by a medical professional, it’s a good starting point to understand your screening eligibility and get the best possible care.

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Last Name*

Email*

Phone*

Date of Birth*

ZIP Code*

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Lung Cancer Screening Eligibility Assessment

Please answer the questions below to better understand whether you qualify for a lung cancer screening. This assessment does not replace an evaluation by a medical professional.

Are you between the ages of 50 and 80?*

Has anyone in your family ever been diagnosed with lung cancer?*

Have you ever been told by your doctor that you have a chronic pulmonary disease such as COPD, chronic bronchitis, or emphysema?*

Are you currently smoking cigarettes, or have you quit smoking within the last 15 years?*

Do you smoke 1 pack of cigarettes a day or more? Do you have a 20-pack smoking history?*

Do you live in a home or work with someone who smokes?*

Total Score

HRA__c

HRA - HRA__c - Case

Request Reason

Area_of_Interest__c

Area of Interest - Area_of_Interest__c - Case

Type

Type - Case

Status

Status - Case

ServiceLine__c

Service Line - ServiceLine__c - Case

Request_Manager__c

Request Manager Request_Manager__c Case

Subject

Subject - Subject - Case

Campus_Submitted__c

Campus Submitted - Campus_Submitted__c - Case

Case Origin

Case Origin - Origin - Case

Line__c

Line - Line__c - Case

ReferralPath__c

ReferralPath - ReferralPath__c - Case

ReferralValue__c

ReferralValue - ReferralValue__c - Case

Referral_Source__c

Referral Source - Referral_Source__c - Campaign

Campaign__c

Campaign - Campaign__c - Case

CampaignChannel__c

Campaign Member - Status

Status - Status - CampaignMember

LeadSource

Lead Source - LeadSource - Contact

Email_Opt_In_Description__c

Email Opt In Description - Email_Opt_In_Description__c - Contact

Campaign Name

This hidden field has been added by Attribution to CRM Plugin to store Campaign Name in this Form's submission table

Campaign Source

This hidden field has been added by Attribution to CRM Plugin to store Campaign Source in this Form's submission table

Campaign Content

This hidden field has been added by Attribution to CRM Plugin to store Campaign Content in this Form's submission table

Campaign Medium

This hidden field has been added by Attribution to CRM Plugin to store Campaign Medium in this Form's submission table

Campaign Term

This hidden field has been added by Attribution to CRM Plugin to store Campaign Term in this Form's submission table

Requested_Physician_Name__c

Preferred Physician - Requested_Physician_Name__c - Case

NPI__c

Guide_Choice__c

Guide Choice - Guide_Choice__c - Case

GCLID (Google Click Identifier)

This hidden field has been added by Attribution to CRM Plugin to store GCLID (Google Click Identifier) in this Form's submission table