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Personal Melanoma Risk Assessment and Tracking Sheet

Monitor Your Skin Health and Risk Factors

Dermatology

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Last updated: Mar 24, 2025

Personal Risk Factors

Static Factors (Check all that apply)

Fair skin, light hair, or light eyes
Family history of melanoma
Personal history of skin cancer
More than 50 moles on body
Presence of atypical moles
History of severe sunburns
Immune system suppression

Monthly Self-Examination Log

ABCDE Checklist for Each Mole

Asymmetry: Note any moles that are not symmetrical
Border: Check for irregular or jagged edges
Color: Document any variations or changes in color
Diameter: Measure moles larger than 6mm (pencil eraser size)
Evolving: Track any changes in size, shape, or color

Body Map Sections

Face and Neck
Chest and Abdomen
Back and Shoulders
Arms and Hands
Legs and Feet

Suspicious Mole Documentation

Date	Location	Size	Color	Changes Noted	Follow-up Required

Sun Exposure Log

Date	Time Outdoors	SPF Used	Protective Clothing	Notes

Professional Skin Checks

Next Appointment: _______________ Last Examination: _______________

Important Contacts

Dermatologist: _________________ Phone: ________________________

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