Medical History Form

Thank you for completing this form. This information will be given to your Doctor.

Your Full Name *

Date of Birth *

Reason for appointment

Are there any specific spots causing concern? *

YesNo, this is a routine check-up

If you selected yes, please specify where the spot is and list any changes you have noticed (colour, size, bleeding, itchy, growing etc)

When did you last have a full skin check? *

Within the last 12 months1-3 years ago3+ years agoNever

Medical History

Medical History (please expand or list other issues in the text box below) *

DiabetesBleeding Disorder (or on Blood Thinners)Autoimmune Condition requiring ImmunosuppressionPrevious Cancer with previous Chemotherapy or RadiotherapyCurrent Cancer & currently undergoing Chemotherapy or RadiotherapyPacemakerImplantable Device other than a Pacemaker (eg. Spinal Cord Stimulator)OtherNone of the above

Medical History - please give more information if any conditions above are ticked. Please also list other medical conditions of note

Current Medications

List any allergies and your reaction if known

Skin and Sun History

When you are outdoors how often do you do each of the following?

Wear a long sleeve shirt/top? *

Most timesSometimesNot usually

Apply Sunscreen on exposed skin? *

Most timesSometimesNot usually

Wear a hat? *

Most timesSometimesNot usually

How often have you actively sunbaked? *

Never1-10 times11-50 times50+ times

Have you ever used a solarium? *

YesNo

Have you ever had a severe Sunburn (large area with redness, blistering and pain)? *

Yes, more than 5 timesYes, 2-5 timesYes, onceNo

What age did you have your first severe Sunburn? (if known) *

Under 10 years of age10-20 years oldOver 20 years oldNever had a severe Sunburn

Have you ever had skin cancer? *

YesNo

If you have had skin cancer, what type?

BCCSCCMelanomaNot sure

Have any 1st or 2nd degree relatives (siblings, parents, children, grandparents, aunts/uncles, nieces/nephews, grandchildren) had skin cancer? *

YesNo

If yes, what type?

BCCSCCMelanomaNot sure

Do you have any other skin problems? Please advise what type (psoriasis, eczema etc).

What is your current job? *

What previous jobs have you done? (jobs that include working outdoors are higher risk for skin cancer) *

If you selected other, please specify where

I confirm that above information I have provided is true, complete and accurate.

Patient Signature *

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Date *

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