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Skin Cancer Survey
Introduction: This screening questionnaire is designed to determine your eligibility for a research study exploring the treatment of skin cancer.
*
What is your age?
(Required.)
Under 30
30-49
50-64
65+
*
Have you ever been diagnosed with skin cancer?
(Required.)
Yes
No
Not sure
*
Which skin cancers have you been diagnosed with?
(Required.)
Basal Cell Carcinoma (BCC)
Squamous Cell Carcinoma (SCC)
Actinic keratoses (AKs)
Melanoma
Other
None of the above
*
Have you ever been told by a doctor that your skin cancer has spread to other parts of your body (beyond the original skin area)?
(Required.)
Yes
No
Not sure