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Corporate & Executive Health
- National Executive Health
- National Corporate Health
Our Services
Industries
Confined Spaces
Resources & Legislations
- Companies We’ve Worked With
About
- Our Team
Contact

Skin Cancer Screening History Form

Please enable JavaScript in your browser to complete this form.

PATIENT INFORMATION

Name *

First

Last

Date of Birth *

Sex *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Email *

If other, please specify

OCCUPATIONAL HISTORY

1. Current Occupation *

2. Duration in Current Job *

(years)

3. Previous Outdoor Occupations

Job Title and Duration

4. Average Daily Sun Exposure *

(hours)

5. Use of Sun Protection (Check all that apply): *

Sunscreen
Protective Clothing
Hats
Sunglasses
Shade Structures
None

Sunscreen SPF level: *

MEDICAL HISTORY

1. Personal History of Skin Cancer *

Yes
No

If yes, please provide Type, Date of Diagnosis and Treatment *

2. Family History of Skin Cancer *

Yes
No

If yes, please provide Relationship and Type *

3. History of Sunburns *

Yes
No

Frequency: *

(e.g., rarely, occasionally, frequently)

Severity *

(e.g., mild, blistering)

4. History of Tanning Bed Use *

Yes
No

Frequency: *

(e.g., never, occasionally, regularly)

Duration *

(e.g., years of use)

SKIN EXAMINATION HISTORY

1. Previous Skin Examinations by a Healthcare Professional *

Yes
No

Date of Last Exam *

Findings *

2. Self-Examinations *

Yes
No

Frequency: *

(e.g., monthly, yearly, never)

Findings: *

(e.g., new moles, changes in existing moles)

SYMPTOMS AND CONCERNS

1. Recent Changes in Skin (within the last year): *

Yes
No

New Moles or Spots *

Yes
No

if yes New Moles or Spots *

Please provide details

Changes in Existing Moles or Spots (size, color, shape) *

Yes
No

if yes Changes in Existing Moles or Spots (size, color, shape) *

Please provide details

Persistent Itching or Bleeding *

Yes
No

if yes Persistent Itching or Bleeding *

Please provide details

2. Current Skin Concerns *

Yes
No

Area of Concern *

Please provide details

Description of Concern *

Please provide details

LIFESTYLE AND RISK FACTORS

1. Smoking History

Current Smoker *

Yes
No

Former Smoker *

Yes
No

Years smoked *

2. Alcohol Consumption *

Yes
No

Frequency *

(e.g., never, occasionally, regularly)

3. Current Medications *

Yes
No

if yes 3. Current Medications *

Please provide details

4. Any Other Relevant Health Issues or Concerns *

Consent for Examination and Information Use:

Medical History Terms & Conditions *

I consent to the skin examination and understand that my information will be used for my medical care.

This form provides a comprehensive overview of the patient’s history and risk factors relevant to skin cancer, allowing the doctor to focus on critical areas during the examination.

Signature *

Clear Signature

Date *

EMPLOYEES HEALTH

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1300 880 804
medicals@employeeshealth.com.au
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