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Lung CT Screening

Is it right for you?
Lung cancer is the leading cause of cancer-related deaths in the United States. If you or a loved one is at risk for lung cancer, it is important to know that early detection may lead to treatment at an earlier stage of the disease — when it is more likely to be curable. At Norton Healthcare, we provide advanced diagnostic testing, including low-dose CT scans that may detect nodules too small to be detected by a chest X-ray.

What is your lung cancer risk?
We encourage you to take a first step in assessing your risk for developing lung cancer. Complete this quick risk assessment. It’s that simple. Our thoracic patient navigator will contact you in the coming days to review your completed risk assessment. For more information, call (502) 629-LUNG (5864).

* Indicates required information
Date *  (mm/dd/yyyy)
Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Home Phone * 
How long have you lived at the above address?  * 
Date of birth * 
Age * 
Race (Please check all that apply) * 

If Other, please specify:

Ethnicity: (Please check one) * 
Do you have a family physician or internist? * 

If No, would you like information regarding a referral? * 

If Yes, please complete the following: 
Physician’s name 
It is recommended that information regarding this screening be forwarded to your physician. 
Would you like your results sent to your physician or internist indicated above? * 

1. Do you smoke? * 

If Yes 
How much?  

If Other, please specify:

What do you smoke?  
If No 
Have you ever smoked?  * 

2. If Yes 
How much did you smoke before you quit?  

If Other, please specify:

How old were you when you quit?  
3. If you currently smoke or have ever smoked, at what age did you start? 
4. Have you ever been exposed to asbestos? (possible if you are or have been an asphalt maker, cement maker, insulation worker, plasters maker, construction worker, maintenance worker, mechanic or plumber) * 

5. Have you been exposed to other products that concern you? (for example, radon, arsenic, chromium, nickel, cadmium, beryllium, silica or diesel fumes) * 

If Yes, please explain 
6. Has an immediate family member had lung cancer? * 

If Yes, who? (Check all that apply.) 

7. Do you have any of the following symptoms? (Check all that apply.) * 

If Other, please specify:

8. Would you be interested in participating in other cancer screenings? * 

9. Would you be interested in participating in cancer studies? * 

10. Would you be interested in receiving genetic information?  * 

11. Would you be interested in information on smoking cessation? * 

Would you be interested in receiving information regarding other Norton Healthcare programs? * 

I understand this assessment is a screening and not a diagnosis, and it is not a substitute for a thorough examination by and consultation with a physician. 
I also understand that I can obtain the benefits of this program only by following the advice of my physician and other health care professionals. 
Electronic Signature * 
Date *  (mm/dd/yyyy)
Email Address 
Authentication * 

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Lung CT Screening Program
Audubon Medical Plaza West
2355 Poplar Level Road, Suite 300
Louisville, KY 40217

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