Contact

Name:

Email:

Phone Number:

City of Residence:

Age:

Gender:
—Please choose an option—MaleFemale

Height (in cm):

Weight (in kg):

BMI (Auto-calculate):

Highest level of education obtained:

Are you currently smoking? (yes or no)
—Please choose an option—YesNo

How old were you when you started smoking?

For how many years in total have you smoked?

On average, how many cigarettes do/did you smoke per day? There are 20 cigarettes in a pack

How many years has it been since you last smoked?

Pack Years (Auto-calculate):

History of lung disease (yes or no)
—Please choose an option—YesNo

Family history of lung cancer (must be blood relative), including parents and siblings
—Please choose an option—YesNo

Exposure to asbestos (yes or no)
—Please choose an option—YesNo

Have you ever been treated for TB? (yes or no)
—Please choose an option—YesNo

Have you ever been diagnosed with cancer? (yes or no)
—Please choose an option—YesNo