Track Your Skin Health and Sun Protection Habits
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Name: _________________ Date of Birth: _________________ Provider: _______________ Next Appointment: ______________
| Date | New Spots Found | Location | Description | Action Taken |
|---|---|---|---|---|
| _____ | ________________ | ___________ | _____________ | _____________ |
| _____ | ________________ | ___________ | _____________ | _____________ |
Time Outside: □ <30 min □ 30-60 min □ 1-2 hrs □ >2 hrs
□ Sunscreen (SPF _____) □ Protective Clothing □ Wide-brimmed Hat □ Sunglasses □ Shade Seeking
1st: _____ 2nd: _____ 3rd: _____ 4th: _____
□ Fair Skin □ Family History of Skin Cancer □ Previous Sunburns □ Outdoor Occupation □ Tanning Bed Use
Dermatologist: _________________ Phone: _____________ Emergency Contact: _____________ Phone: _____________
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