Skin Lesion Assessment Form
Please complete this form to assist in the evaluation and documentation of your skin lesion.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Information (Email Address)
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Lesion
*
Please Select
Face
Scalp
Neck
Trunk
Arm/Hand
Leg/Foot
Other (please specify)
Lesion Characteristics
*
Rows
Size (mm)
Shape
Color
Border
Primary Lesion
Round
Oval
Irregular
Other
Brown
Black
Red
Pink
Blue
Skin-colored
Other
Regular
Irregular
Blurred
Sharp
How long have you had this lesion?
*
Please Select
< 1 month
1-3 months
3-12 months
> 1 year
Not sure
Have you noticed any of the following changes in the lesion? (Select all that apply)
*
Increase in size
Change in color
Change in shape
Bleeding
Itching
Pain
Ulceration (open sore)
None of the above
Do you have a personal or family history of skin cancer?
Yes, personal history
Yes, family history
No
Not sure
Do you have any of the following risk factors? (Select all that apply)
Fair skin
History of sunburns
Frequent sun exposure
Use of tanning beds
Immunosuppression
Large number of moles
None of the above
Please upload a clear photo of the lesion (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
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Additional Notes or Comments
Submit Assessment
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