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IMAGING REQUEST
CT CHEST LUNG CANCER SCREENING
(IMG4556)
PATIENT INFORMATION
NAME
ON PRECAUTION
DIABETIC IS OR MAY BE PREGNANT
WHEELCHAIRDOBMRN IV
02
STRETCHERED
BLIND
DISORIENTEDINDICATION
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How to fill out lung cancer screening form
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Gather all necessary information such as personal details, medical history, and insurance information.
02
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Submit the completed form to the healthcare provider or facility offering the lung cancer screening.
Who needs lung cancer screening form?
01
Individuals who are at high risk for developing lung cancer, such as current or former smokers aged 55 to 80 years old.
02
Individuals with a family history of lung cancer or other risk factors as determined by a healthcare provider.
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What is lung cancer screening form?
Lung cancer screening form is a document used to assess an individual's risk of developing lung cancer.
Who is required to file lung cancer screening form?
Individuals who meet certain criteria or have been recommended by their healthcare provider are required to file lung cancer screening form.
How to fill out lung cancer screening form?
Lung cancer screening form can be filled out by providing personal information, medical history, and answering questions about smoking habits and exposure to other risk factors.
What is the purpose of lung cancer screening form?
The purpose of lung cancer screening form is to identify individuals who may benefit from early detection and intervention for lung cancer.
What information must be reported on lung cancer screening form?
Information such as demographics, medical history, smoking habits, and exposure to environmental risk factors must be reported on lung cancer screening form.
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