Lung Cancer Risk Assessment

Personal Information

About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Have you Has the patient ever been seen at Roswell Park? Yes No

Patient MRN

How did you hear about Roswell Park?

Please explain *

General Information

Your The Patient's Contact Information

Your Patient's Phone number * (###-###-####)

Alternate phone (###-###-####)

Your Patient's Email Address *

Best time to call

Would you the patient like to join our mailing list? Yes No

Your Patient's Insurance Information Optional

Primary insurance provider

ID number (Letters and Numbers only)

Secondary insurance provider

ID number (Letters and Numbers only)

Your The Patient's Physician Information Optional

Primary physician

Primary physician's phone (###-###-####)

Referring physician

Referring physician's phone (###-###-####)

Risk Assessment

Prior Cancer Treatment

Have youHas the patient ever been treated for cancer of the head or neck, lung or esophagus? * Please note, this excludes cancer of the thyroid. Yes No

Please indicate which type of cancer you havethe patient has received treatment for: * Head or Neck Lung Esophageal

Date youthe patient received yourtheir last treatment for Head or Neck cancer *

Date youthe patient received yourtheir last treatment for Lung cancer *

Smoking History

Do youDoes the patient now, or have youhas the patient ever smoked cigarettes? * Yes No

If pack years are at least 20, ELIGIBLE

Have youHas the patient smoked within the last 15 years? * Yes No

If yes, ELIGIBLE

Are youIs the patient interested in stopping smoking? * Yes No

For additional smoking cessation tips please call the New York State Smoking Quit Line (NYSSQL) at 1-866-697-8487

Employment

Are youIs the patient an active firefighter? * Yes No

Which fire department do youdoes the patient work for? *

Are youIs the patient an employee of Gernatt? * Yes No

How many years were youwas the patient employed? *

Please choose a preferred location for the appointment * Buffalo - Roswell Park Comprehensive Cancer Center Main Hospital Jamestown - Jamestown Medical Oncology & Hematology Niagara Falls - Roswell Park Niagara, Williams Road Orchard Park - Roswell Park Hematology Oncology Southtowns Eddy — Mobile Lung Cancer Screening (dependent on schedule)

Your Patient's Residential Address