If your client has a history of Skin cancer, please answer the following:


      Agent Name:  



   Client Name: 



   Phone:  



   Fax: 
   

   
   1.  Date of diagnosis ?  


   2.  What type of skin cancer was diagnosed ?
        Basal Cell Carcinoma
        Squamous Cell Carcinoma
        Malignant Melanoma


   3.  Where was the skin cancer located ?  


   4.  Has the cancer metastasized (spread) beyond the skin ? Yes   No 

       If yes, give details: 


   5.  Has there been any evidence of recurrence ? Yes   No 

       If yes, give details: 


   6.  For malignant Melanoma only, what stage was the cancer ?
        Clark I/in-situ
        Clark II/Breslow < = 0.75mm
        Clark III/Breslow .75 - 1.5mm
        Clark IV/Breslow 1.51 - 4.0mm
        Clark V/Breslow > 4.0mm


   7.  Is your client on any medication ? Yes   No 

       If yes, give details: 


   8.  Does your client have any major health problems ? Yes   No 

       (example: heart disease, etc.)

       If yes, give details: