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Apex Dermatology & Skin Surgery Center – Cleveland, OH Dermatology

Apex Dermatology & Skin Surgery Center serves the greater Cleveland area with offices in Concord, Solon, Mayfield Heights, Parma and Hudson Cleveland, OH. Call today!

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Skin Cancer Risk Assessment (Beta)

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Skin Cancer Risk Assessment (Beta)

Skin Cancer Risk Assessment

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Name*
First Last
Email*
Consent*
I agree to the privacy policy.

Age*
- Under 24
- 25-34
- 35 - 44
- 45 - 54
- 55+
Skin Type*
- Fair/Pale
- Olive/Light Brown
- Brown/Dark Brown

Has anyone in your immediate family ever been diagnosed with melanoma?*
- Yes
- No
Have you ever been diagnosed with melanoma?*
- Yes
- No
Have you ever been diagnosed with a form of basel cell cancer, squamous cell cancer or any other form of skin cancer other than melanoma?*
- Yes
- No
Have you ever received a kidney, liver or heart transplant?*
- Yes
- No

Have you ever been diagnosed with Lymphoma?*
- Yes
- No
Do you take any immunosuppressant medications to treat a medical condition?*
- Yes
- No
Have you ever had exposure to radiation, such as a radiation treatment for cancer?*
- Yes
- No

Have you ever gone indoor tanning?*
- Yes
- No
How many times in your life have you had a blistering sunburn?*
- Never
- 5 times or less
- 6 - 19 times
- 20+ times
Has a doctor ever removed a mole from your skin that wasn't cancerous?*
- Yes
- No

How often do you wear sunscreen?*
- Every day, all year long, rain or shine
- Only when outside on a sunny day
- Rarely or never
How often are you outside for your job, sport or hobby?*
- Less than 5 hours / week
- Between 5 - 15 hours/ week
- 15+ hours / week

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Email*
Phone*
Reason for Inquiry*
Preferred Office*
Preferred Appointment Date(s)

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Reason for Appointment
Health Insurance Plan

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Questions or Comments

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