Dermatology — Skin Cancer Screening Template

Visit Information

Date: [Date]
Visit type: Annual screening / Surveillance / Spot check
Last skin exam: [Date]
Screening indication: Routine / High-risk surveillance / Concern for specific lesion

Risk Factor Assessment

Personal History

Prior skin cancer:

• Melanoma: None / [Date, location, stage, treatment]
• Basal cell carcinoma: None / [Number, locations, treatments]
• Squamous cell carcinoma: None / [Number, locations, treatments]
• Other: [Specify]

Precancerous lesions:

• Actinic keratoses: None / Few (<10) / Moderate (10-20) / Extensive (>20)
• Dysplastic nevi: None / [Number, history of removal]
• Lentigo maligna: None / [Details]

Prior biopsies: [Number, locations, results]

Family History

Melanoma: None / [Relationship, number affected]
NMSC: None / [Relationship]
Pancreatic cancer: None / [Relationship] — (associated with CDKN2A)
Other cancers: [Relevant hereditary syndromes]

Sun Exposure History

Fitzpatrick skin type: I / II / III / IV / V / VI

• Type I: Always burns, never tans
• Type II: Usually burns, tans minimally
• Type III: Sometimes burns, tans uniformly
• Type IV: Burns minimally, tans well
• Type V: Rarely burns, tans profusely
• Type VI: Never burns, deeply pigmented

Blistering sunburns:

• Childhood (<18 years): None / 1-5 / >5
• Adulthood: None / Few / Many

Sun exposure:

• Occupational: Indoor / Outdoor — Years: [X]
• Recreational: Minimal / Moderate / Significant
• Tanning bed use: Never / Former / Current — [Number of sessions]

Geographic history: [High UV exposure regions]

Other Risk Factors

Immunosuppression: None / [Reason: transplant, medications, HIV]

• Duration: [X] years
• Medications: [List]

Radiation history: None / [Site, reason, date]
Chemical exposures: None / [Arsenic, coal tar, etc.]
PUVA history: None / [Number of treatments]
Genetic syndromes: None / [Xeroderma pigmentosum, nevoid BCC syndrome, etc.]

Calculated Risk Level

Overall skin cancer risk: Low / Moderate / High / Very High
Melanoma risk: Low / Moderate / High
Recommended screening interval: [X months/years]

Review of Systems

Constitutional: [ ] Unintended weight loss [ ] Fatigue [ ] Night sweats
Skin: [ ] New lesion(s) [ ] Changing lesion(s) [ ] Non-healing wound [ ] Bleeding lesion
Lymphatic: [ ] Lymph node swelling
Neurological: [ ] Headaches [ ] Numbness (relevant for local invasion)

Physical Examination

General

Appearance: Well-appearing / [Concerns]
Skin type: Fitzpatrick [I-VI]
Overall sun damage: None / Mild / Moderate / Severe
General comments: [Tanned, fair, freckling, etc.]

Total Body Skin Examination

Scalp:

[ ] Examined with comb/part hair
Findings: Clear / [Lesions described]

• Actinic keratoses: None / [Number, locations]
• Seborrheic keratoses: None / [Description]
• Suspicious lesions: None / [Description]

Face:

Forehead: Clear / [Findings]
Temples: Clear / [Findings]
Nose: Clear / [Findings]
Cheeks: Clear / [Findings]
Perioral: Clear / [Findings]
Ears: Clear / [Findings]

• Right: [Helix, antihelix, lobule, posterior]
• Left: [Helix, antihelix, lobule, posterior]

Periorbital: Clear / [Findings]

Neck:

Anterior: Clear / [Findings]
Posterior: Clear / [Findings]
Lateral: Clear / [Findings]

Chest:

Clear / [Findings]
Actinic keratoses: None / [Number]
Seborrheic keratoses: None / [Description]

Abdomen:

Clear / [Findings]

Back:

Upper back: Clear / [Findings]
Mid back: Clear / [Findings]
Lower back: Clear / [Findings]
Actinic damage: None / Mild / Moderate / Severe

Upper Extremities:

Right arm:

• Shoulder: Clear / [Findings]
• Upper arm: Clear / [Findings]
• Forearm: Clear / [Findings]
• Hand dorsum: Clear / [Findings]
• Palm: Clear / [Findings]
• Nails: Clear / [Findings]

Left arm:

• Shoulder: Clear / [Findings]
• Upper arm: Clear / [Findings]
• Forearm: Clear / [Findings]
• Hand dorsum: Clear / [Findings]
• Palm: Clear / [Findings]
• Nails: Clear / [Findings]

Lower Extremities:

Right leg:

• Thigh anterior: Clear / [Findings]
• Thigh posterior: Clear / [Findings]
• Knee: Clear / [Findings]
• Lower leg: Clear / [Findings]
• Ankle: Clear / [Findings]
• Foot dorsum: Clear / [Findings]
• Sole: Clear / [Findings]
• Web spaces: Clear / [Findings]
• Nails: Clear / [Findings]

Left leg:

• Thigh anterior: Clear / [Findings]
• Thigh posterior: Clear / [Findings]
• Knee: Clear / [Findings]
• Lower leg: Clear / [Findings]
• Ankle: Clear / [Findings]
• Foot dorsum: Clear / [Findings]
• Sole: Clear / [Findings]
• Web spaces: Clear / [Findings]
• Nails: Clear / [Findings]

Buttocks:

Clear / [Findings]

Genitalia:

Examined: Yes / No / Deferred
Findings: Clear / [Findings]

Lymph Node Examination

Cervical: No adenopathy / [Findings]
Axillary: No adenopathy / [Findings]
Inguinal: No adenopathy / [Findings]

Nevus Count

Total nevi (>2mm): <50 / 50-100 / >100
Atypical nevi: None / [Number]
Atypical mole syndrome criteria: Met / Not met

Lesions of Concern

Lesion 1

Location: [Anatomic site]
Clinical description:

• Size: [X] mm
• Color: [Description]
• Shape: [Description]
• Border: [Description]

ABCDE Assessment:

• A (Asymmetry): No / Yes
• B (Border irregularity): No / Yes
• C (Color variation): No / Yes
• D (Diameter >6mm): No / Yes
• E (Evolution): No / Yes / Unknown

"Ugly Duckling": Yes / No
Dermoscopy:

• Global pattern: [Description]
• Network: [Findings]
• Dots/globules: [Findings]
• Streaks: [Findings]
• Blue-white structures: [Findings]
• Vascular pattern: [Findings]
• Dermoscopic diagnosis: [Likely benign / Suspicious / Highly suspicious]

Clinical impression: [Diagnosis]
Plan: Monitor / Photograph / Biopsy / Excision

Lesion 2 (if applicable)

[Repeat above format]

Lesion 3 (if applicable)

[Repeat above format]

Actinic Keratoses

Number: None / [X]
Distribution: [Locations]
Prior treatment: None / [Treatment type, response]
Treatment today: None / [Cryotherapy, etc.]

Other Findings

Seborrheic keratoses: None / Multiple — [Locations, notable ones]
Dermatofibromas: None / [Locations]
Angiomas: None / [Locations]
Lentigines: None / [Locations]
Other benign findings: [List]

Photography

Total body photography: Not performed / Performed / Updated
Baseline photography: Established / New today
Individual lesion photos: [List lesions photographed]
Dermoscopic images: [List lesions imaged]

Assessment

1) Skin cancer risk: [Low / Moderate / High / Very High]
Based on: [Key risk factors]
2) [Specific findings requiring action]

• [Lesion, location] — [Clinical impression]

3) Actinic keratoses — [None / Mild / Moderate / Extensive]
4) [Other diagnoses]

Plan

Biopsies Today

[ ] Biopsy performed: [Location] — Type: Shave / Punch [size]
Clinical indication: [Reason]
Pathology pending

Treatments Today

[ ] Cryotherapy: [Locations, number of lesions]
[ ] Other: [Treatment]

Monitoring Plan

• [ ] Short-term follow-up: [Lesion] in [X] weeks/months
• [ ] Baseline photography recommended
• [ ] Sequential dermoscopy monitoring for: [Lesion locations]

Prescriptions

[If applicable — sunscreen, treatment for AKs, etc.]

Patient Education

• Skin self-examination technique reviewed
• ABCDE criteria explained
• Sun protection counseling:
• Broad spectrum SPF 30+ sunscreen
• Protective clothing and hats
• Seek shade during peak UV hours (10am-4pm)
• Avoid tanning beds
• Warning signs requiring urgent evaluation

Follow-up

Next full skin exam: [X] months/year

• Based on risk level: [Risk level]

Sooner if: New concerning lesion, changing lesion, non-healing wound

Referrals

[ ] Mohs surgery: [Lesion, location]
[ ] Oncology: [If indicated]
[ ] Genetics: [If hereditary syndrome suspected]

Summary Statement

[Patient name] is a [age]-year-old [male/female] with [risk level] skin cancer risk presenting for [routine/surveillance] skin examination. [Number] concerning lesion(s) identified for [monitoring/biopsy]. [Number] actinic keratoses treated with [treatment]. Next examination recommended in [X months/years].