Skin Cancer Screening Questionaire

Please fill out this questionaire and bring it with you to your skin cancer screening.

 

Name: ______________________

Phone Number: ______________

Please answer the following questions the best you can.

1) Over your lifetime have you spent a little, an average amount or a lot of time in the sun? Circle answer.

 

2) On average, how many hours do you spend in the sun daily?

 

3) Have you had skin cancer before? If yes, what kind and where?

 

4) Do you have any areas on your body that you are concerned may be cancer?

 

5) Have any of your family members had cancer, or have it now?

 

6) Please list any other skin conditions you have.