Patient Name(Required) Email(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required) Marital Status(Required)SingleMarriedDivorcedCell Phone(Required) Emergency Contact(Required) Address(Required) City(Required) State(Required) Zipcode(Required) Residence Type(Required) Employment Status(Required) Tobacco UseIn the last 30 days, have you used tobacco?(Required) Smoked - YES Smoked - NO Used a smokeless tobacco product(Required) YES NO Have you ever used tobacco in last 15 years?(Required) Smoked - YES Smoked - NO Average Smoking Years(Required) Average Packs Per day(Required) Average Packs Smoking Years(Required) HiddenTYLDCT(Required) Not Recommend LDCT LDCT(Required) Recommend LDCT Would you be interested to Perform LDCT Yes No Interested in LDCT If Accept then Send in a referral for Prior Authorization for LDCT to KRMC & write Referral sent to KRMC for LDCT Not Interested in LDCT Patient Refused LDCT LDCT CounselingAge No of Pack-Year Current Smoker or Years since quit Sign and Symptoms of Lung Cancer Yes No Counseling Checklist Patient Counseled that LDCT will help find the effect of Smoking on the Lungs and help identify Nodules or masses that might need a follow up. Advised the it has low dose radiation exposure. Patient understand that we would need annual LDCT. Patient if needed will undergo treatment. Patient counseled to quit smoking. Patient understand the importance of smoking abstinence. Would you be interested in quitting tobacco Yes No Patient Counselled to Quit Smoking Wellbutrin Chantix Nicotine Patches Refused to use any of above Recommended Quantity 21 mg/hr 14 mg/hr 7 mg/hr Patient Refused to use any of above Δ
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