CheckYourLungs.org | Assessment

Lung Cancer Screening Assessment

Disclaimer: This assessment is intended to be a guide only. Results should not replace the medical advice from your physician. If you have any questions about your risk of lung cancer, please consult your physician. If you are eligible for the Lung CT screening, you may receive a follow-up call from our team to assist you in scheduling the screening.

Screening information

Screenings are by physician referral only. Our program follows eligibility guidelines from the National Lung Screening Trial:

Are between the ages of 50 and 77
Calculate your average packs per day and times by the years you smoked. If your number is 20 or greater, then you qualify. For example, one pack a day for 20 years or two packs a day for 10 years equals 20.
Meet the above criteria and currently smoke or have quit within the last 15 years
Have no symptoms or history of lung cancer

Assessment form

Step 1: Basic information about yourself

First Name:

Last Name:

Gender:

Date of Birth: (MM/DD/YYYY)

Zip Code:

Phone:

Email:

Step 2: Current physician status

If you do not currently have a physician, please leave the following two fields empty.

Physician name:

Practice name:

Step 3: Smoking/Tobacco history

Do you have a history of smoking or using tobacco?

Step 4: Finish!

Lung Cancer Screening Assessment

Call 717-544-5941 to schedule a screening.