Fitzgerald Skin Type Assessment Form
Client Name:
Date:
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
DOB:
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Day
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Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email Address:
example@example.com
Section 1 - Genetic Disposition
What is the natural color of your eyes?
Light blue, grey, green = 0
Blue, grey, green = 1
Hazel or light brown = 2
Dark brown = 3
Brownish black = 4
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What is your natural hair color?
Sandy red = 0
Blonde = 1
Chestnut/dark blonde = 2
Dark brown = 3
Black = 4
What is your untanned skin color?
Reddish = 0
Very pale = 1
Pale with beige tint = 2
Light brown = 3
Dark brown = 4
Do you have freckles on unexposed areas?
Many = 0
Several = 1
Few = 2
Incidental = 3
None = 4
Total Section 1:
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Section 2 - Reaction to Sun Exposure
Question
What happens when you stay too long in the sun?
Painful redness, blistering, peeling = 0
Blistering followed by peeling = 1
Burns moderately = 2
Burns minimally = 3
Rarely burns = 4
To what degree do you turn brown?
Hardly or not at all = 0
Light tan = 1
Reasonable tan = 2
Tan very easily = 3
Turn dark brown quickly = 4
Do you brown within several hours after sun exposure?
Never = 0
Seldom = 1
Sometimes = 2
Often = 3
Always = 4
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How does your face react to the sun?
| Very sensitive = 0 ||
| Sensitive = 1 ||
| Normal = 2 ||
| Very resistant = 3 ||
| Never had a problem = 4 ||
Total Section 2:
Section 3 - Tanning Habits
Question
When did you last expose yourself to sun or tanning beds?
More than 3 months ago = 0
2-3 months ago = 1
1-2 months ago = 2
Less than 1 month ago = 3
Less than 2 weeks ago = 4
Total Section 3:
Final Score
Total Score:
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Rows
Fitzpatrick Skin Type
0-6 Type I
7-13 Type II
14-20 Type III
21-27 Type IV
28-34 Type V
35+ Type VI
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