Register Interest in Lung Cancer Test

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Nominator

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Patient Information

*Title :

*First name:

*Last name:

*Email address:

*Contact telephone number:

*Address line 1:

*Address line 2:

*Address line 3:

*Town:

*County:

*Postcode:

*Country:

*Gender: Male Female

*Height: Ft, In Or Cm

*Weight: lb Or Kg

*Date of Birth: / /

*Ethnicity:

Clinical History

*Do you currently smoke? Yes No

*If yes, please check all that apply

Cigarettes

Cigars

Pipe

Other

*If no, have you ever smoked? Yes No

*How much did you / do you smoke? Cigerettes per day

*What year did you start smoking?

*If you've stopped smoking, what year did you stop smoking?

Have you ever worked in an environment where you experienced prolonged exposure to the following?

*Secondhand Smoke Yes No

*How Many Years?

*Radon Yes No

*How Many Years?

*Asbestos Yes No

*How Many Years?

*Do you have any close relatives that have been diagnosed with lung cancer? Yes No

*If so, what was your relationship? :

Have you ever been diagnosed with or experienced any of the following?:

Tuberculosis

Berylliosis

Silicosis

Scarring on the lungs

Recurring Pneumonia

Bronchitis

Persisitent cough

Productive cough

Shortness of breath during normal activity

GP Information

*Name :

*Practice :

*Address line 1:

*Address line 2:

*Address line 3:

*Town:

*Postcode:

*Country:

*Telephone:

*Fax: