Are You at Risk of Skin Cancer ?

Skin Lesions or Moles on Your Skin *

Do you have many moles on your skin?

Not Many

Over 100

Prior Skin Cancer *

Have you previously had any type of skin cancer?

Yes

No

Family History *

Have you previously had any type of skin cancer?

Yes

No

Sun Burns *

Have you had multiple blistering or peeling sunburns?

Never

Occasionally

Regularly

Solarium Useage *

Have you used a solarium bed for tanning?

Never

Yes

Work Environment *

Do you work outdoors or spend many hours outside?

Yes

No

Your Skin Now *

Do you have a something on your skin that looks different or is sore, itchy or bleeding, and hasn’t settled down for more than 2-3 weeks?

Yes

No

Name *

First Name

Last Name