Skin Cancer Screening

Athlete Name: ______________________ Age:_______ M_____ F_____ Date:____________________ Sport:_________________ Family/Personal History: 1.) Do you have any family members who have been diagnosed with any pre-cancerous lesion or skin cancer? No_____ Yes______ explain________________________________________ 2.) Have you ever been diagnosed with a pre-cancerous lesion or skin cancer?
type:__________________________ location:_______________________________ year _______________ treatment________________________________________________ 3.) 4.) Do you currently use a tanning bed? No_____ Yes______ How often?__________________ Do you have a history of any memorable sunburns? No_____ Yes_____ How many?___________

5.)

Do you routinely wear sunscreen while you participate in outdoor athletics? Yes____ No____ If no, why not?_______________________________________________

6.)

Do you have any existing or new moles, freckles, or skin issues that you are concerned about (changes in color, size, shape, bleeding, etc)? No_____ Yes______

7.)

Would you like to be referred to a dermatologist to discuss these issues? No_____ Yes_____

This section to be filled out by the Athletic Trainer. Circle the answer(s) that are true for each athlete. 8.) Approximately how many moles does the athlete have? 0-5
9.)

6-10

11-15

16-20

20 or more

Circle applicable risk factors: light hair light eyes light skin family history pre-cancer/skin cancer personal history of pre-cancerous lesion/skin cancer *photosensitising medication ____________________

increased freckles increased nevi (moles) 10.)

history of at least 1 burn in the last year immunosuppression

Referral to Dermatologist? No________ Yes______

*Does the athlete take any medication that cautions them about exposure to the sun.