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Lung Cancer Screening Survey
Please complete this short survey to see if you qualify to participate in this study.
1.
Please leave your name, phone number, and email for us to contact you should you qualify for this trial.
Name:
Phone #:
Email:
2.
Are you at least 50 years old?
Yes
No
3.
Do you currently, or have you smoked cigarettes?
Yes
No
4.
How many years did you smoke?
5.
How many (estimated) packs per day did you smoke?
6.
Have you been diagnosed with cancer (except for skin cancer) within the last five years?
Yes
No
7.
Are you receiving any cancer treatment now?
Yes
No
8.
Have you ever had an organ, tissue, or bone marrow transplant?
Yes
No
9.
Are you currently pregnant?
Yes
No