Skin Cancer Questionnaire
Introduction:
The following questionnaire aims to gather essential information regarding your skin health and
potential risk factors for skin cancer. This questionnaire is designed to assist healthcare
professionals in assessing your risk level and determining appropriate preventive measures or
further evaluation if necessary. Please answer all questions to the best of your ability. Your
responses will remain confidential and will only be used for medical assessment purposes.
Instructions:
● Answer each question honestly and to the best of your knowledge.
● If a question does not apply to you, please mark "N/A".
● If you are unsure about a question, provide your best estimate.
● Feel free to provide additional information or details where relevant.
Demographic Information:
1. Full Name:
2. Age:
3. Gender:
4. Date of Birth:
5. Contact Information (optional):
Medical History:
Do you have a history of skin cancer?
If yes, please specify the type(s) and approximate date(s) of diagnosis:
Have any immediate family members (parents, siblings, children) been diagnosed with skin
cancer? If yes, please specify the relationship and type(s) of cancer:
Do you have a history of excessive sun exposure or sunburns, especially during childhood or
adolescence? If yes, please provide details:
Skin Characteristics:
Skin Type (Select One):
Type I: Always burns, never tans (pale white; blond or red hair; blue, green, or hazel
eyes).
Type II: Usually burns, tans minimally (white; fair; blond or red hair; blue, green, or hazel
eyes).
Type III: Sometimes mild burn, gradually tans (cream white; fair with any hair color; blue,
green, or hazel eyes).
Type IV: Rarely burns, tans easily (moderate brown).
Type V: Very rarely burns, tans very easily (dark brown).
Type VI: Never burns, deeply pigmented (black).
Do you have multiple moles (more than 50) or atypical moles (dysplastic nevi)? If yes, please
specify the approximate number:
Behavioral Factors:
Do you frequently use tanning beds or engage in indoor tanning activities?
How often do you apply sunscreen when outdoors? Please specify the SPF (Sun Protection
Factor) of the sunscreen you use, if known:
Do you wear protective clothing (e.g., wide-brimmed hat, long-sleeved shirt) and sunglasses
when exposed to sunlight for extended periods?
Symptoms and Concerns:
Have you noticed any changes in the size, shape, color, or texture of moles or skin lesions?
If yes, please describe:
Do you experience any itching, pain, tenderness, or bleeding in any skin area? If yes, please
specify the location and duration:
Additional Information:
Is there any other relevant information about your skin health or sun exposure history that you
would like to share?
Conclusion:
Thank you for completing the Skin Cancer Questionnaire. Your responses will aid in our
assessment of your skin health and risk factors for skin cancer. Please schedule a follow-up
appointment with your healthcare provider for further evaluation and recommendations based
on your responses. If you have any urgent concerns or symptoms, please seek medical
attention promptly.
