Genetic Disposition
What best describes your eye color?
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Light blue, gray (0)
Green (1)
Blue (2)
Brown (3)
Dark Brown (4)
What is your natural hair color?
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Red (0)
Blond (1)
Chestnut, dark blond (2)
Dark brown (3)
Black (4)
What is the color of your skin (non-exposed areas)?
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White (0)
Very pale (1)
Pale with a beige tint (2)
Light brown (3)
Dark brown (4)
Do you have freckles on unexposed areas?
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Many (0)
Several (1)
Few (2)
Incidental (3)
None (4)
Reaction to Sun Exposure
What happens when you stay in the sun?
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Painful redness, blistering, peeling (0)
Blistering followed by peeling (1)
Burns sometimes followed by peeling (2)
Rare burns (3)
Never had burns (4)
To what degree do you brown?
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Hardly or not at all (0)
Light color tan (1)
Reasonable tan (2)
Tan very easily (3)
Turn dark brown very quickly (4)
Do you turn brown within several hours after sun exposure?
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Never (0)
Seldom (1)
Sometimes (2)
Often (3)
Always (4)
How does your face react to the sun?
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Very sensitive (0)
Sensitive (1)
Normal (2)
Very resistant (3)
Never had a problem (4)
Tanning Habits
When did you last expose your body to the sun or artificially tan?
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More than 3 months ago (0)
Two to three months ago (1)
One to two months ago (2)
Less than a month ago (3)
Less than two weeks ago (4)
Did you expose the area to be treated to the sun?
Please Select
Never (0)
Hardly ever (1)
Sometimes (2)
Often (3)
Always (4)
Total Score
Skin Type Score
Fitzpatrick
0 to 7
I
8 to 16
II
17 to 25
III
26 to 30
IV
Over 31
V-VI
I attest that the above information is true and understand that my provide relies on this information to provide safe and effective treatment
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