The ‘Additional Risk Factors’ section is not required; however, these data elements help create a more comprehensive database for lung cancer analyses.


Field Name

Description

Education Level

Select patient’s highest level of education.

Radiation exposure - documented high exposure levels

Select the appropriate response.

Occupational exposures to agents that are identified specifically as carcinogens targeting the lungs

Select all responses that apply.

History of cancers that are associated with an increased risk of developing a new primary lung cancer

Select all responses that apply.

Lung cancer in first-degree relative (mother, father, sister, brother, daughter or son with history of lung cancer)

Select the appropriate response.

Family history of lung cancer, other than first-degree relative

Select the appropriate response.

COPD (chronic obstructive pulmonary disease)

Select the appropriate response.

Pulmonary Fibrosis

Select the appropriate response.

Second hand smoke exposure

Select the appropriate response.


After all required fields have been completed, enter the Name of the Person Who Completed the Paper Form. If this name has not been previously entered in an exam record, then enter the person’s first and last name. In the future, the name will appear in the drop-down list for this field. If the name has been previously entered, click the arrow and select it from the drop-down list.

Note: If paper forms were not used, please enter the name of the person completing the on-line form.


The Name of Person Submitting this Form and Submission Date fields are populated automatically.


Click the Submit button. You must correct any errors before the form will be accepted. If no errors are detected, a confirmation message appears and the exam moves to Completed status.



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Within 1-Year'
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