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Skin Check Form Template

Streamline Your Skin Assessments with This Template

Monitoring skin issues can be overwhelming, especially when you need to keep track of your health. This skin check form template is designed for healthcare professionals and individuals looking to document skin conditions, ensuring consistent assessments. By using this template, you can simplify health record-keeping, enhance communication with dermatologists, and track changes effectively over time. Plus, our form is compliant with WCAG standards for accessibility. Start using this helpful tool now!

Use this Template (FREE) Live Preview
Full name
Date of birth
Email
Phone number
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Preferred appointment date
Preferred contact method
Phone call
Text message
Email
No preference
What is the main reason for your skin check today?
Routine full-body skin check
Concern about a specific spot
Follow-up on a previous skin issue
New patient establishing care
Other/Not sure
Which areas are you concerned about? (Select all that apply)
Please describe any spots, moles, or changes you are concerned about
Have you noticed any of the following? (Select all that apply)
Have you ever been diagnosed with skin cancer?
Yes
No
If yes or unsure, what type?
Melanoma
Basal cell carcinoma (BCC)
Squamous cell carcinoma (SCC)
Actinic keratoses (precancerous spots)
Other/Unsure
Not applicable
Do any first-degree relatives have a history of melanoma?
Yes
No
How does your skin react to sun without protection?
Always burns, never tans
Usually burns, tans minimally
Sometimes burns, gradually tans
Rarely burns, tans easily
Never burns, tans deeply
Not sure
How often do you apply sunscreen on exposed skin?
Never
Rarely
Sometimes
Often
Always
Do you have many moles (about 50 or more)?
Yes
No
Not sure
Do you take blood thinners (e.g., warfarin, aspirin, clopidogrel)?
Yes
No
Not sure
Are you currently on medications that affect your immune system (e.g., steroids, chemotherapy, biologics)?
Yes
No
Not sure
Anything else we should know about your health or skin?
Any allergies to adhesives, antiseptics, or local anesthetics?
Yes
No
Not sure
I consent to a visual skin examination and understand that no procedures will be performed without additional consent.
Yes
No
I agree to be contacted about scheduling, reminders, and follow-ups.
Yes
No
Type your full name as signature
Signature date
I confirm the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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paper art illustration featuring a skin check form template with sections for information and assessment

When to use this form

Use this form before facials, peels, waxing, laser services, or any appointment where skin history matters. Estheticians, med spas, and salons use it to record skin type, concerns, photos, and risk factors. Ask clients about new moles, rashes, sun exposure, and sensitivity so you can spot red flags and guide next steps. It helps you triage: reassure, schedule treatment, or refer to a clinician. It is also helpful at annual screenings or before seasonal promotions. If you serve walk-ins, this keeps your team consistent and compliant. Pair it with the Beauty salon client intake form to capture broader contact and consent, and with the Makeup appointment form when matching products to allergies and skin goals.

Must Ask Skin Check Questions

  1. What area or spot do you want us to evaluate today?

    This focuses the exam, ensures proper draping, and helps you document exact locations for follow-up. It also distinguishes a spot check from a full-body review, saving time and improving accuracy.

  2. When did you first notice it, and how has it changed (size, color, shape, border, itching, bleeding)?

    Timing and ABCDE-type changes help you gauge urgency and rule out irritation vs. something suspicious. Clear timelines support better referrals and photo comparisons over time.

  3. Do you have a personal or family history of skin cancer, atypical moles, or precancerous lesions?

    History informs risk and how often you should schedule checks. It also guides when to escalate to a dermatologist for assessment.

  4. How much sun exposure do you get, and what protection do you use (SPF, clothing, tanning beds)?

    Exposure and habits shape your prevention advice and aftercare plan. Documenting protection levels also explains photosensitivity reactions that may appear later.

  5. What medications, allergies, or recent procedures could affect your skin (retinoids, isotretinoin, antibiotics, peels, laser)?

    These factors change sensitivity, healing, and bleeding risk, which affects what you can safely do today. If the client also books add-ons, align details with the Eyelash extension appointment form to avoid conflicting aftercare.

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