Healthy Lungs in Florida Screening Program Application(ALL fields on this form are required.) Personal Information First Name: Last Name: Address: Address: City/Town: State/Province: - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code: Home Phone: Mobile Phone: Email Address: Ethnicity: American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity/Other Ethnicity Other: Date of Birth: Date of Birth:: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of Birth:: Day Day12345678910111213141516171819202122232425262728293031 Date of Birth:: Year Year192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Gender at Birth: Male Female Rather Not Disclose Are you or have you ever served in the armed forces or been a firefighter? Yes No If yes, how many years of service? Do you currently have a prescription for a Low-Dose CT Lung Cancer screening exam? Yes No Criteria for Low-Dose Lung Cancer Screening CT Scan (To qualify, you must answer True to all of the requirements below) You are between 50 - 80 years old. True False You have no signs or symptoms of lung cancer. (Ex: weight loss that is unexpected, shortness of breath, coughing up blood, etc.) True False Either you currently smoke or have quit smoking within the past 15 years. True False You have a 20 Pack-Year* smoking history. True False *How to calculate your pack-year:20 pack-year smoking history should be calculated off of when you smoked the most.There are 20 cigarettes in one pack. If you smoked 10 per day, that equals .5 pack.(How many cigarettes you smoked per day / 20) x how many years you smoked = Your Pack Year Other Medical Questions Have you been diagnosed with lung cancer? Yes No If yes, please provide details: Have you ever been exposed to toxic substances? Yes No If yes, please provide details: Have you ever been advised by a healthcare professional to undergo lung cancer screening? Yes No If yes, please provide their Name: If yes, please provide their Phone Number: Are you a current smoker? Yes No Have you been explosed to second hand smoke? Yes No Financial Information Gross Annual Household Income: Occupation: Reason for financial hardship (e.g. medical expenses, loss of income ect.): Declaration I hereby declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in the rejection of my application. By agreeing to participate in this program, individual agrees to share information protected by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) with the FLHC and the healthcare provider administering the scan. Additionally, information may be collected for research purposes with the aim of contributing to lung cancer screening awareness and furthering the mission of the FLHC. This information will not be shared outside of the FLHC and your provider. By typing your name below, you are agreeing that the information contained in this application is correct. Date: Date:: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date:: Day Day12345678910111213141516171819202122232425262728293031 Date:: Year Year2024202520262027202820292030 Leave this field blank