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Skin Screening Program
Thank You for submitting the Dermatology New Problem History Form
Date
Name
Sex
M
F
Age
DOB
Tel
Drug Allergies & Special Considerations :
None
List
Problems / Lesions
Skin Screening-Spot-Check:
Spot
Growth
Acne
Itching
Rash
Other Skin Problems, Please Describe:
Location / Where is it? Please List:
Onset/ How did it appear?
Sudden
Gradual
Duration? When did you notice it?
Days
Weeks
Months
Years
Symptoms &/or change in your spots:
Any change in size shape color etc?
No
Yes
Please List
Irritated, Painful, Bleeding, Unsightly?
No
Yes
Please List
Personal &/or Family History:
Any type of cancer, melanoma etc?
No
Yes
Please List
Other conditions?
No
Yes
Please List
Other relevant Information?
No
Yes
Please List
Consent to do Spot Check - Enter Digital ID & Date:
I know Spot Check is not a substitute for complete Skin evaluation.
Sign:
I am free to seek full exam & care from any physician of my choice.
Date:
I release Dr. Khan from any liability in connection with this screening.
Patient
Parent
Guardian
Spot Check Review & Clinical Impression:
Benign lesions can turn cancerous. Any change => Consult a Dermatologist
Borderline:Needs Follow Up=>Advise Dermatologist
Consult
Benign Appearance:Any change=>Consult a Dermatologist
Advise
Suspicious=>Advise Diagnostic Testing & Treatment
Treatment
Dr. Mushtaq A. Khan's Recommendations:
Avoid Unnecessary Sun exposure, Seek Shade, Wear Protective Clothing, Apply sunscreens & Use UV Blocking Sunglasses regularly.Any Change in a lesion or a new growth should be evaluated as soon as possible. Early detection can be life saving.The only sure way to differentiate between Benign & Cancerous mole/growth with almost 100% accuracy is by Pathology Examination.Please seek a dermatology evaluation if you notice any change in your condition, symptoms or develop a new lesion of any type.
Please join us in promoting Sun Protection & offering Skin Cancer Screenings to save lives by making generous donations:
Single Spot-Check is provided free of charge to all deserving persons.
We request a regular dermatology visit for multiple skin spot problems.
Our goal is to save lives by promoting Prevention, Early Detection & Prompt Treatment of Skin Cancers.
Mushtaq A. Khan, M.D., Board Certified Dermatologist