MELANOMA QUESTIONNAIRE - Insurance Network America 2026

1. Click ‘Get Form’ to open the MELANOMA QUESTIONNAIRE in our editor.
2. Begin by entering your personal information at the top of the form, including your name and age or date of birth.
3. Fill in the date you were diagnosed with melanoma, along with your height and weight.
4. Indicate how your cancer was treated by checking the appropriate boxes for surgery, chemotherapy, or radiation, and provide relevant dates.
5. Specify the stage of melanoma by selecting from the provided options. If lymph nodes were involved, indicate 'YES' or 'NO' and specify how many if applicable.
6. Answer questions regarding metastatic disease, Breslow thickness, Clark’s level, and any ulceration noted on pathology reports.
7. Check any relevant medical history boxes and provide additional details as necessary.
8. Complete the section regarding tobacco use and any other major health impairments or medications you are taking.
9. Finally, ensure to attach any requested pathology reports for a more comprehensive submission.

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