Karmanos Lung Cancer Screening Program

*Indicates required information

Contact Information

Health Information

Smoking Information

Has a health care provider ever told you that you have COPD or emphysema? *

Yes

No

Have you had a chest X-ray in the last 3 years? *

Yes

No

Have you had a chest CT scan in the last 3 years? *

Yes

No

Do you currently smoke cigarettes? (if you have never smoked, skip the next 3 questions) *

Yes

No

For how many total years have you smoked (even if you have quit)?

What is the average number of packs you smoked each day?

If you have quit smoking, how long has it been since you quit?

Name of your primary care physician *

Phone Number of primary care physician: *