Sample, Sammy G ST0001

Lung Screening and Surveillance Intake Form 1234567890


The participant was identified as a potential lung screening candidate by:

Eligible based on chart review?


Intake discussion

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Smoking History

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Additional information can be provided on the background form

MM/DD/YYYY
Location if not in VA
MM/DD/YYYY
Location if not in VA

Veteran of age and exposure to cigarette smoke as described above, and without a current diagnosis or obvious symptoms suggestive of lung cancer, has been educated today about the estimated risk for lung cancer, the possibility of a cure or life prolonging if an early lung cancer were to be found during screening, the possibility of imaging abnormalities not being lung cancer, the possibility of complications from additional diagnostic procedures, and the approximate amount of radiation exposure associated with each screening procedure. In addition, the Veteran has been educated today about the importance of avoiding exposure to cigarette smoke, available tobacco cessation programs and available lung screening services at this VA facility. Education material was provided to the veteran.


Current Status


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