Client Consultation Form Page 8
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8Skin Type Worksheet
Patient's Name:
Date:
Score:
0
1
2
3
4
What is the color of your
LIGHT BLUE,
BLUE, GRAY
BROWNISH
BLUE
DARK BROWN
eyes?
GRAY OR GREEN
OR GREEN
BLACK
What is the natural color of
CHESTNUT,
SANDY RED
BLOND
DARK BROWN
BLACK
your hair?
DARK BLOND
What is the color of your skin
PALE WITH BEIGE
REDDISH
VERY PALE
LIGHT BROWN
DARK BROWN
(unexposed areas)
TINT
Do you have Freckles on SUN
MANY
SEVERAL
FEW
INCIDENTAL
NONE
exposed areas?
BURNS
PAINFUL
BLISTERING
What happens when you stay
SOMETIMES
NEVER HAD
REDNESS,
FOLLOWED BY
RARELY BURNS
in the sun too long?
FOLLOWED BY
BURNS
PEELING
BLISTERING
PEELING
TURN DARK
To what degree do you turn
HARDLY OR NOT
LIGHT COLOR
REASON-ABLE
TAN VERY EASILY
BROWN
brown?
AT ALL
TAN
TAN
QUICKLY
Do you turn brown several
NEVER
SELDOM
SOMETIMES
OFTEN
ALWAYS
hours after sun exposure?
How does your face respond
NEVER HAD A
VERY SENSITIVE
SENSITIVE
NORMAL
VERY RESISTANT
to the sun?
PROBLEM
When did you last expose
MORE THAN 3
2-3 MONTHS
1-2 MONTHS
LESS THAN 1
LESS THAN 2
yourself to the sun, tanning
MONTHS AGO
AGO
AGO
MONTH AGO
WEEKS AGO
bed, or tanning creams?
Do you expose the area to be
NEVER
HARDLY EVER
SOMETIMES
OFTEN
ALWAYS
treated to the sun?
TOTAL SCORE:
SCORE
FITZPATRICK SKIN TYPE
0-7
I
II
8-16
17-25
III
25-30
IV
OVER 30
V-VI
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0 votes
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