Tell Us a Little Bit More About Yourself!
We will only be using the information provided here for educational purposes. We will not disclose any of this information. Please fill out the questionnaire and place it in the box. Thank you.
1. How old are you?
2. What is your sex?
3. What is your race/ethnicity?
4. What city, state do you live in?
5. What is your marital status?
6. What is your family income?
7. What is your employment status?
8. What is the highest level of education that you completed?
9. Do you have insurance?
10. If yes, what kind of insurance do you have?
11. Have you been told by a doctor that you have lung cancer (diagnosed with lung cancer)?
12. Have you been told by a doctor that you have any type of cancer that is that is not lung cancer?
13. If yes, what kind?
14. Do you have a family history of any cancer?
15. If yes, which family member(s) and what type(s) of cancer?
16. Did they smoke?
17. Do you smoke? (if you have smoked less than 100 cigarettes, you are not considered a smoker)
18. If yes, what is your smoking status?
19. If you are a current or previous smoker, how many packs a day do you/did you smoke?
20. If you are a current or previous smoker, how many years did you smoke for?
21. If you no longer smoke, when did you quit?
22. Have you ever been exposed to second-hand smoke?
23. If yes, how long have you been exposed to second-hand smoke?
24. If yes, in what setting were you exposed to second hand smoke? (check all that apply)
25. Have you received any of the following (check all that apply)?
26. Have you ever had a chest X-ray to get screened for lung cancer specifically?
27. If yes, when? (month and year if possible)
28. In the past 12 months, have you received a chest X-ray?
29. In the past 12 months, have you received a chest X-ray, specifically for lung cancer?
30. Have you ever had a CT scan to get screened for lung cancer?
31. If yes, when? (month and year if possible)
32. In the past 12 months, have you received a CT scan?
33. In the past 12 months, have you received a CT scan, specifically for lung cancer?
34. Before today, how much did you know about lung cancer screening through CT scans?
35. Have you ever heard about lung cancer screening?
36. If yes, where did you hear about it from?
37. Before today, did you believe you were eligible for lung cancer screening?
38. After hearing about lung cancer screening from ALCSI, do you now think you are eligible for lung cancer screening?
39. If you are eligible for lung cancer screening, when do you expect to receive your next CT scan to check for lung cancer? This question is ambiguous. Some may not know whether they are eligible
40. Do you feel more inclined to talk to your doctor about getting screened after learning about lung cancer screening from the American Lung Cancer Screening Initiative?
41. If you are eligible for lung cancer screening, would you like to be screened?
42. If no, why?