Patient Consent Form For Laser Genesis Skin Therapy Treating Warts Page 3
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4Fitzpatrick Classification Questionnaire
SCORE
0
1
2
3
4
What is the natural color
Chestnut, dark
Sandy red
Blond
Dark brown
Black
of your hair?
blond
Light blue,
Blue, Gray,
Brownish
What is the eye color?
Blue
Dark Brown
Gray, Green
Green
Black
What is the color of sun
Pale with beige
Reddish
Very pale
Light brown Dark brown
unexposed skin areas?
tint
How many freckles on
Many
Several
Few
Incidental
None
unexposed skin areas?
Painful
Burns,
What happens when you
Blistering
redness,
sometimes
Never had
are in the sun TOO long
followed by
Rarely burns
followed by
blistering,
a problem
without sunblock?
peeling
peeling
peeling
How well do you turn
Hardly or not
Light color
Tan very
Turn dark
Reasonable tan
brown?
at all
tan
easily
very quickly
Do you turn brown within
one day of sun
Never
Seldom
Sometimes
Often
Always
exposure?
How does your face
Very
Never had
Very sensitive
Sensitive
Normal
respond to the sun?
resistant
a problem
When did you last
expose yourself to the
More than 3
2-3 month
Less than 1
Less than 2
1-2 months ago
sun or artificial sun
months ago
ago
month ago
weeks ago
treatments?
Do you expose the area
Never
Hardly ever
Sometimes
Often
Always
to be treated to the sun?
TOTAL
00-07 points = Skin type I
!
08-16 points = Skin type II
!
17-25 points = Skin type III
!
25-30 points = Skin type IV
!
30-40 points = Skin type V & VI
!
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