Consult Intake Form Page 4
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4Sonoma Vein Aesthetic & Laser Specialists
A Department of Santa Rosa Cardiology
500 Doyle Park Drive, Suite 205. Santa Rosa, CA 95405
Phone: 707-636-8346 Fax: 707-205-1008
Fitzpatrick Skin Classification
Please circle appropriate answers below
Score
Question
0
1
2
3
4
What is the color
Light Blue/
Gray
Blue
Brown
Dark Brown/
of your eyes?
Green
Black
What is the
Sandy Red
Blonde
Chestnut/
Dark Brown
Black
natural color of
Dark Blonde
your hair?
What is the color
Reddish
Very Pale
Pale with
Light Brown
Dark Brown
of your skin?
Beige Tint
(unexposed areas)
Do you have
Many
Several
Few
Incidental
None
freckles on SUN
exposed areas?
What happens
Painful
Blistering,
Burns
Rarely Burns
Never Burns
when you stay in
Redness and
followed by
sometimes,
the sun too long?
Blistering
peeling
followed by
peeling
To what degree
Hardly or not
Light color or
Reasonable
Tans very
Turn Dark
do you turn
at all
Tan
Tan
easily
Brown quickly
brown?
Do you turn
Never
Seldom
Sometimes
Often
Always
brown several
hours after sun
exposure?
How does your
Very Sensitive
Sensitive
Normal
Very
Never had a
face respond to
Resistant
problem
sun?
When did you last
Never
Hardly Ever
Sometimes
Often
Always
expose yourself to
sun?
Total Score:
Score
Fitzpatrick Skin Type
0-7
I
8-16
II
17-25
III
25-30
IV
Over 30
V-VI
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