Dr. Peng Skin Wellness
Mole Checks & Skin Cancer Screening — Pre-Visit Questionnaire
You may simply review these questions or complete this form before your visit. Advance completion and printing are optional. If you are unsure, select “Unsure” and we can discuss it during your appointment.
Name:
Date of birth (DD / MM / YYYY): Date:
1 Your reason for visiting
What brings you in today? Select all that apply.
Have you noticed a new or changing mole or other skin spot?
Does any spot repeatedly bleed, crust, itch, hurt or fail to heal?
If yes to either question, where is it, how long has it been there, and what changes have you noticed?
2 Your skin history
Have you ever been diagnosed with melanoma?
If yes, year(s) and body site(s):
Have you ever been diagnosed with another skin cancer, such as basal cell carcinoma (BCC) or squamous cell carcinoma (SCC)?
If yes, type, year(s) and body site(s):
Has a doctor told you that you have atypical or dysplastic moles?
Have any of these moles been biopsied or removed?
Have you had a full-body skin examination or photographic mole mapping?
If yes, when and which examination?
3 Family history
Has a parent, sibling or child been diagnosed with melanoma?
If yes, relationship(s), number affected and approximate age(s) at diagnosis:
4 Your moles and sun exposure
Approximately how many moles do you have? A rough estimate is fine.
Without sunscreen, how does your skin usually respond to strong sun exposure? Select the closest answer.
Have you had severe or blistering sunburns, especially in childhood or adolescence?
Have you used indoor tanning beds or tanning sunlamps?
If used, approximately how many years?
Do work, sports or other activities regularly expose you to the sun?
If yes, please describe:
5 Medical conditions and medicines
Do you have a condition, or take medicines, that weaken your immune system?
If yes, list the condition and/or medicines (or bring your medication list):
Have you had an organ transplant?
If yes, type and year:
Before your visit
Please bring any previous skin biopsy reports, mole-mapping records or photos showing changes over time. You do not need to know every answer or count all your moles.
This form supports your consultation. It does not diagnose skin cancer or replace a skin examination.