Skin Examination Intake · Dr. Blinkhorn & Dr. Whiting Family Practice

Patient Information

Full Name *

Date of Birth *

Health Card Number (CPN) *

Phone Number *

Sex * Used to direct you to the appropriate patient information and consent form

Skin Type & Characteristics

Fitzpatrick Skin Type * Select the description that best matches your skin’s natural response to sun exposure

Natural Eye Colour

Natural Hair Colour

Sun Exposure History

Do you work outdoors, or have you had significant outdoor occupational sun exposure?

Have you ever used an indoor tanning bed?

How many blistering sunburns did you have before age 18? A blistering sunburn means the skin actually blistered or peeled severely

How many blistering sunburns have you had in total over your lifetime?

Personal Medical History

Have you ever been diagnosed with skin cancer?

Have you ever been told you have atypical or dysplastic moles?

Have you ever had radiation treatment to any part of your body?

Have you ever had a full skin examination before?

Family History

Has a first-degree relative (parent, sibling, or child) ever been diagnosed with melanoma?

Immune System

A suppressed immune system increases the risk of skin cancer. Please indicate if any of the following apply to you.

Organ transplant recipient

Long-term oral steroid use (e.g. prednisone)

Biologic medications for rheumatoid arthritis, psoriasis, or inflammatory bowel disease(e.g. Humira, Enbrel, Remicade, Stelara)

Other immunosuppressive condition or medication

None of the above

Medications

Certain medications taken long-term can increase photosensitivity or skin cancer risk.

Long-term tetracycline or doxycycline (antibiotic)

Hydrochlorothiazide (HCTZ) — a blood pressure / fluid tablet

Neither of the above

Current Concerns

Please let us know if you have noticed any of the following. You do not need to know the medical terms — just describe what you have observed.

Do you have a mole that looks noticeably different from all the others on your body — one that stands out as the “odd one out”?

Have you noticed any mole or lesion that has changed in size, shape, or colour in the last 6 months?

Do you have a spot that has been persistently itching, bleeding, or has not healed for more than 3 weeks?

Any other skin concerns you would like us to be aware of?

Purpose of Today’s Visit

Please note: We do not perform a full skin examination at the same visit as an initial consultation unless this was specifically arranged in advance by your referring physician. If you are unsure, please select below and we will clarify at your visit.

Full skin examination — this was specifically arranged in advance Assessment of a specific lesion or area of concern Both — I have a specific concern and a full exam was arranged Not sure — please advise at the visit

Skin Examination Intake Form