History and Intake Form
Past Medical History:
Other (Including any other type of cancer or any other problems you see a doctor for or take medicine for)
Past Surgical History:
Skin Disease History:
Do you wear Sunscreen?
Do you tan in a tanning salon?
Do you have a family history of Melanoma?
Social History:
Cigarette Smoking:

Alcohol Use Per Day

How often do you exercise?

What is your caffeine use?

Patient Data:


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