MUSC MOBILE HEALTH UNIT SKIN QUESTIONNAIRE

Screening Site:
Screening Date:
RadDatePicker
RadDatePicker
Open the calendar popup.
  1. What is your First Name:   Middle Initial:  Last Name: 
  2. What is your Date Of Birth?
    RadDatePicker
    RadDatePicker
    Open the calendar popup.
     
  3. Are you Hispanic?
  4. Which of these groups best describes you?






     
  5. What is the highest level of school you have completed?




  6. What is your Zip Code?  
  7. If the MUSC Mobile Health Unit had not come to your community, would you have gotten a Skin Screening this year?
  8. What about the MUSC Mobile Health Unit made it easier for you to get a Skin Screening today? (Check all that apply)







     
  9. Have you ever had skin cancer?
    If YES, was it melanoma?
  10. When was your last Skin Screening?




  11. Do you have any moles that have changed recently in size, color, or shape?
  12. Was is your skin complexion?



  13. What is your smoking status?

    -> How long has it been since you quit?years


MOBILE HEALTH UNIT STAFF ONLY