Melanoma/Skin Cancer

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Melanoma/Skin Cancer Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
What type of skin cancer was diagnosed?
- Basal cell carcinoma
- Squamous cell carcinoma
- Malignant melanoma
- Dysplastic nevi syndrome
Date of diagnosis:
MM slash DD slash YYYY
Date of last treatment:
MM slash DD slash YYYY
Number of lesions:
Location of skin cancer(s):
How has the cancer been treated?
- Surgery
- Other
If surgery, provide date(s):
If Other, please describe:
Clark Level of the cancer (malignant melanoma only):
- I(1)
- II(2)
- III(3)
- IV(4)
- V(5)
Breslow Scale of the cancer (malignant melanoma only):
- In-situ
- 0.74 mm or less
- 0.75 mm to 1.50 mm
- 1.51 mm to 4.00 mm
- 4.01 mm plus
TNM Stage
- T1a
- T1b
- T2a
- T2b
- T3a
- T3b
- T4a
- T4b
- Any N1-3
- M1
Any evidence of recurrence?
- Yes
- No
If yes, provide details:
Any family history of melanoma?
- Yes
- No
If yes, provide details:
Any family history of dysplastic nevi syndrome?
- Yes
- No
If yes, provide details:

Medications

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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken

List any other major health problems the client has:
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