Please provide the following contact information:

*First Name
*Last Name
*Street Address
Address (cont.)
*City
*State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zipcode
Work Phone
*Home Phone
Cell Phone
*E-mail
*Retype E-mail
Smoking, Clinical, Occupational / Environmental History
*Cigarette Smoking	Current Smoker Ex-Smoker Never Smoker
If Ex-Smoker, Please Indicate the Year You Quit Smoking Completely
If Current or Ex-Smoker-	Age Started
*Current Age-	years old
If Current or Ex-Smoker-Total Number of Years Smoking
Required If Current Smoker-Number of cigarettes currently smoked per day (For your Benefit Please Be Accurate: Do not count any recent attempts at cutting down, even one puff on a cigarette counts as a fully smoked cigarette	Cigarettes per day
Required If Current or Ex-Smoker-Average Number of Cigarettes Smoked per day for All Your Smoking Years (For your Benefit Please Be Accurate: Even One Puff on a Cigarette Counts as a Fully Smoked Cigarette	Cigarettes per day
If Current or Ex-Smoker -Your Preferred Brand of Cigarettes	Filtered? Filtered Unfiltered   Be Advised:  There is no health benefit with filtered cigarettes!
Other Tobacco Use: (Check all that apply)	Cigars              Years Used:      Year Quit:
	Pipes               Years Used:      Year Quit:
	Spit Tobacco   Years Used:      Year Quit:
Have You Ever Had Any Prolonged or Repeated Exposure to:
	Asbestos (found in: mining, insulation work, brake lining, etc.) - Yes No    Years of Exposure:
	Radioactive Materials (found in: uranium ores, radon gas, etc.)  - Yes No   Years of Exposure:
	Arsenic (found in: electronics, sprays, insecticides, etc.)  - Yes No            Years of Exposure:
	Nickel or Chromium (found in: manufacturing, mining, refining, etc.)  - Yes No   Years of Exposure:
	Iron Oxides (found in: boiler-scaling, sand blasting, etc.)   - Yes No           Years of Exposure:
	Chlormethyl Ether (found in: bactericides, fungicides, etc.) - Yes No        Years of Exposure:
	Secondary Cigarette Smoke  - Yes No   Years of Exposure:
	Please List Any Other Known Occupational, Environmental or Toxic Exposures and the Years of Exposure
Lung Symptoms and Diseases (Check All that Apply)
	Coughing - Yes No     Coughing Blood  - Yes No
	Productive Cough (Coughing up Sputum or Phlegm)  - Yes No
	Chest Pain, Tightness, or Aching  - Yes No     Hoarse Voice - Yes No
	Wheezing, Rattling, Chest Whistling  - Yes No
	Shortness of Breath at Rest  - Yes No                                                  Shortness of Breath With Exertion  - Yes No
	Frequent Chest Colds  - Yes No
	Pneumonia or Severe or Recurrent Bronchitis  - Yes No
Has a Doctor Ever Told You Have or Had:
	Tuberculosis  - Yes No    Emphysema  - Yes No     Asbestosis  - Yes No
	Silicosis  - Yes No     Chronic Obstructive Pulmonary Disease  - Yes No
	Any Other Pulmonary Diseases or Diagnosis:
	Have You Ever Had Cancer?  - Yes No   Please Indicate Which Part(s) of the Body was (is) affected?
	Has Any Blood Relative(s) Ever Been Diagnosed With Lung Cancer?  - Yes No     If Yes, What is That Relative(s) Relationship to You?
	Have You Had a Chest X-Ray or Chest CAT Scan in the Last 6 Months  - Yes No                 If Yes, What Were the Results:
Please contact me about ordering LungPATH	Yes No
Questions or Comments? Send an email to info@StopSmokingDoctors.com