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 are 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.

Your Fitzpatrick Skin Type:

Skin Type Score Fitzpatrick Skin Type
0-7 I
8-16 II
17-24 III
25-30 IV
Over 30 V

 

 

Leave this empty:

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Signature Certificate
Document name: Fitzpatrick Skin Type Form
lock iconUnique Document ID: 0c3b2ff633ab20f293fff12b17ed6259a1ff305a
Timestamp Audit
June 30, 2023 1:14 pm PSTFitzpatrick Skin Type Form Uploaded by Skinlogic Med Spa - infossc2001@gmail.com IP 73.169.190.108