Health History Questionnaire
To ensure the most accurate and thorough examination, please follow the guidelines below for best results from your appointment.
Patient Information
Full Name: __________________________________________________________
Ontario Health Card Number and Version Code: _ _ _ _ – _ _ _ – _ _ _ – _ _
Date of Birth (YYYY/MM/DD): _ _ _ _ / _ _ / _ _
Phone: ____________________________________________________________
Email: _____________________________________________________________
Emergency Contact (Name & Phone): ___________________________________
Family Physician (Name): _____________________ Phone: _______________________
Personal Medical History
Do you have many (20+) moles or freckles on your body? ☐ Yes ☐ No
Do you have fair skin? ☐ Yes ☐ No
Do you have light hair? ☐ Yes ☐ No
Do you have light-colored eyes? ☐ Yes ☐ No
Height _____ (cm/in)
Family History
Has anyone in your family been diagnosed with skin cancer? ☐ Yes ☐ No
If yes, who and what type? _______________________________________________
Lifestyle & Risk Factors
Do you use sunscreen regularly? ☐ Always ☐ Sometimes ☐ Rarely ☐ Never
Have you experienced frequent or severe sunburns (especially as a child)? ☐ Yes ☐ No
Do you currently use tanning beds? ☐ Yes ☐ No
Have you ever used tanning beds? ☐ Yes ☐ No
If yes to either of the above, approximately how many times? ________
Do you spend long periods outdoors for work or recreation? ☐ Yes ☐ No
Please specify: __________________________________________________________________
Skin Health
Do you have any moles or spots that you are concerned about?
☐ Yes ☐ No
If yes, where are they approximately located?_____________________________________________________________________
Do you have any moles or spots that you have noticed changing?
☐ Yes ☐ No
If yes, where are they approximately located and describe the changes (colour, size, shape, or other)?_____________________________________________________________________
Have you ever been diagnosed with skin cancer?
☐ Yes ☐ No
If yes, what type and when? ________________________________________________________________________________________________________________
Have you had any pre-cancerous or suspicious moles/lesions removed?
☐ Yes ☐ No
If yes, please describe: ____________________________________________________________________________________________________________________
Do you have a history of other cancers or major illnesses?
☐ Yes ☐ No
If yes, please list: _____________________________________________________________________
Do you currently take any medications (including creams or supplements)?
☐ Yes ☐ No
If yes, please list: _____________________________________________________
__________________________________________________________________
Do you have any allergies to medications, latex, or adhesives?
☐ Yes ☐ No
If yes, please list: _____________________________________________________
Do you have any experience with epilepsy, ocular light sensitivity or ocular nerve damage/diseases?
☐ Yes ☐ No
If yes, please specify:___________________________________________________
Contact Us Today
Stratford Skin Cancer Screening
Stratford Medical Centre
444 Douro Street, 2nd Floor
Stratford, ON, N5A 0E6
Tel: (519) 643-8459
Email: info@StratfordSCS.ca