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CMN Africa Database
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* Indicates required question
First Name of Patient:
*
Your answer
Surname of Patient:
*
Your answer
Gender:
*
Female
Male
Other:
Names of Parents (in case of minor):
*
Your answer
Profession/ Profession of Parents:
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Place of Birth & Nationality:
*
Your answer
Does the patient have any siblings?
Your answer
Location of CMN:
*
Scalp
Face
Arm
Both Arms
Hand
Both Hands
Shoulder
Main Trunk
Back
Chest
Stomach
Leg
Both Legs
Foot
Both Feet
Numerous CMN (smaller CMN on various or all parts of the body)
Other:
Required
Has the CMN been treated?
*
No
Partially Removed
Removed
Prefer not to answer
If the CMN has been treated, please elaborate:
Your answer
Has the patient had an MRI pertaining to the CMN?
*
Yes
No
Prefer not to answer
Other:
What were the findings of that MRI?
Your answer
Has the patient been diagnosed with Neurocutaneous Melanocytosis (NCM)?
Yes
No
Clear selection
Attending GP/ Paediatrician (with contact details):
*
Your answer
Attending Dermatologist (with contact details):
*
Your answer
Attending Neurologist (with contact details):
*
Your answer
Attending Surgeon (with contact details):
*
Your answer
Other Doctors (with contact details):
*
Your answer
Home Address:
*
Your answer
Mobile Number:
*
Your answer
E-Mail Address:
*
Your answer
Other comments:
Your answer
Do you agree to have your pictures/ CMN stories published on social media/ our website/ printed information/marketing materials?
*
Yes
No
Other:
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