SoFHA Patient Forms

CT Lung Screening

Description:

The SoFHA Imaging Center CT lung screening form.

Code:

19.004

Issued:

01/01/2022

Revision:

Revised:

N/A

CT Lung Screening

Legal NameFirst, MI, Last

Date of Birth

Weight (lbs)

Have you had any of the following?

Radon Exposure

Occupational exposure to carcinogens (arsenic, chromiu, asbestos, nickel, cadmium,beryllium, silica, diesel fumes, coal smoke, and soot)

Family history of Lung Cancer n First-Degree Relative (parents, sibiliings, or children)

History of COPD, emphysema, or chronic bronchitis

Personal history of head and neck cancer or bladder cancer

History of rhemmatologic diseases of the lung (ie. Sarcoidosis, Lupus, etc.)

Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Patient/Guardian Signature