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Melanoma

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Melanoma

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Gender *

What is your complaint?

What are your complaints?

A new mole

Change in the mole

When did you notice it?

How do you define this change?

ABCDE Criteria

Asymmetry (the difference between the two halves in shape and pattern when the mole is divided in two on the horizontal and vertical axis

Irregular, blurred, indented-protruding mole edges

Presence of more than two colors, especially pink, red, white, gray-blue, black color

Larger than 6 mm

Being different from others

Change in diameter, color and pattern in the mole in the last 6 months-1 year

Nodular Findings

It starts as a raised, swollen shape on the skin

Being rubbery

To be growing

Additional Information

Did you have your mole, which was the subject of the complaint, removed?

Yes

Have you had any mole(s) taken before?

Yes

Have you ever been diagnosed with melanoma?

Yes

If you have been diagnosed with melanoma, what is its location and do you have any additional tests and treatments?

Have you ever been diagnosed with dysplastic nevus (especially high grade)?

Yes

If you have been diagnosed, what is its location?

What is the number of moles on your body?

Less than 10

11-20

21-50

51-100

More than 100

Do you have regular follow-ups in a center for your moles?

Yes

Is there any melanoma in family history?

Do you have any other diseases?

Please state the medications you take on a regular basis (with doses)

Inspections

No diagnostic procedures

Pathology result of the mole which is the subject of the complaint

Pathology result of your mole taken before

Pathology result of diagnosis of melanoma

Pathology result of dysplastic nevus

Photo of the mole which is the subject of the complaint

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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