Lung Cancer High Risk Assessment Form

Roswell Park’s High Risk/Early Detection Lung Cancer Screening Program is for people who are concerned about their risk of developing lung cancer.

Answer the questions below to help our lung cancer experts assess your risk level for lung cancer.

* indicates required field

Tobacco Use
If no, please proceed to question #11.
years
packs per day
Contact Information
You have completed the high-risk lung cancer assessment form. In order to determine your eligibility for the high-risk screening program, please fill out the form below to submit your assessment to an RPCI cancer information specialist. You may also contact them at 1-877-ASK-RPCI (1-877-275-7724) to do an over-the-phone evaluation.
HIPAA: Patient Privacy
Due to HIPAA regulations, Roswell Park will not be able to identify itself to someone other than you who may answer the phone or in a voice message, unless you indicate otherwise.