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Table 1 Melanoma recurrence data sheet

From: Exploring patterns of recurrent melanoma in Northeast Scotland to inform the introduction a digital self-examination intervention

Surname:

DOB:

Forename(s):

Gender:

CHI:

 

Occupation:

Ethnicity:

Date of primary melanoma diagnosis:

 

Melanoma type:

 

Stage of melanoma:

 

Tumour thickness (mm):

Breslow depth;

Clark level;

Prognostic features:

Ulceration;

Lymph node involvement;

Tumour vascularity;

lymphovascular invasion;

Mitotic rate;

Regression;

Microsatellites;

Tumour-infiltrating lymphocytes;

Lactate dehydrogenase serum level;

Tumour anatomical location:

 

Method/Details of treatment:

 

Details on how the melanoma was picked up:

 

Date of excision biopsies:

Primary biopsy;

Secondary biopsy;

Punch/Shave biopsy;

Details of prescribed follow-up program:

 

Date of recurrence diagnosis:

 

Nature of recurrence: local, regional, distant)

 

Melanoma type:

 

Melanoma stage:

 

Tumour thickness:

Breslow depth;

Clark level;

Prognostic features:

 

Tumour anatomical location:

 

How was the recurrence detected:

 

Please Tick

 

Self – detected

 

GP

 

Dermatologist

 

Follow-up appointment

 
 

Other

 

If other, please state:

If self- detected, which of the following apply:

 

Please Tick:

Recurrence found via;

Routine self-examination

 
 

Accidental find

 
 

Aid of partner/Acquaintance

 
 

Experience of related symptoms (e.g. nausea, fatigue, weight loss, pain, shortness of breath etc.)

 

Route from self-detection to official diagnosis: (e.g. Patient – GP – Hospital)

 

Dates of above referrals: (e.g. GP referral, treatment dates etc.)