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Fitzpatrick Skin Type Form

Score	0	1	2	3	4
1. What is your eye color?	Light Blue, Gray, green	Blue-Gray, green	Blue	Dark Brown	Brownish Black
2. What is the natural color of your hair	Sandy Red	Blond	Chesnut/Dark Blond	Dark Brown	Black
3. What is the color of your skin(non- exposed areas)?	Reddish	Very Pale	Pale with Beige Tint	Light Brown	Dark Brown
4. Do you have freckles on unexposed areas?	Many	Several	Few	Incidental	None

Please total your score for ALL 4 QUESTIONS above - Genetic Disposition:

Score	0	1	2	3	4
1. What happens when you stay too long in the sun?	Painful redness, blistering, peeling	Blistering, followed by peeling	Burns sometimes followed by peeling	Rare burns	Never had burns
2. To what degree do you turn brown?	Hardly or not at all	Light color tan	Reasonable tan	Tan very easy	Turn dark brown quickly
3. Do you turn brown within several hours of exposure?	Never	Seldom	Sometimes	Often	Always
4. How does your face react to the sun?	Very Sensitive	Sensitive	Normal	Very Resistant	Never had a problem

Please total your score for ALL 4 QUESTIONS above - Sun Exposure:

Score	0	1	2	3	4
1. When did you last expose your body to the sun (or tanning bed/tanning cream?	More than 3 months ago	2-3 months ago	1-2 months ago	Less than a month ago	Less than 2 weeks ago
2. Did you expose the area to be treated to the sun?	Never	Hardly Ever	Sometimes	Often	Always

Please total your score for ALL 2 QUESTIONS above -Tanning Habits:

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Please add the total of the 3 boxes above and select the checkbox for the corresponding total.

0-7

8-16

17-24

25-30

Over 30

Your Fitzpatrick Skin Type:

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Timestamp

Audit

June 30, 2023 1:14 pm PST

Fitzpatrick Skin Type Form Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 67.168.123.88