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EMR template
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Enter Patient Data
This will allow you to calculate the patient's lung cancer risk, according to
this model
.
Age:
Gender:
Male
Female
Number of years this patient has smoked cigarettes:
During this patients years as a smoker, how many cigarettes per day did this patient smoke, on average? (1 pack=20 cigarettes)
Has the patient quit smoking?
Yes
No
How many years ago did the patient quit smoking?
Has the patient been exposed to asbestos at work?
Yes
No
I don't know
By selecting "yes" you are confirming that you meet all of the following criteria: You worked in one or more of the following occupations: asbestos worker, insulator, lagger, plasterboard worker, dry waller, plasterer, ship scaler, ship fitter, rigger, shipyard boilermaker, shipyard welder, shipyard machinist, shipyard coppersmith, shipyard electrician, plumber/pipefitter, steamfitter, or sheet metal worker. You worked in this job for at least 5 years. You began working in this job at least 15 years ago.
Which facility are you affiliated with?
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Ann Arbor
Charleston
Portland
Cincinnati
New York Harbor
Minneapolis
Providence
Durham
Other — VA
Other — non-VA
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