Client Skin Analysis
Standard client skin analysis form. Preserve the original question wording and logical grouping from the PDF reference. All fields are optional unless specified.
Client Information
Name
*
Date of Consult
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
City
*
State
*
Zip
*
Age
Gender
Medical / Background
Known Allergies
Medications
Fitzpatrick Skin Type
Fitzpatrick Classification
*
Please Select
Type I
Type II
Type III
Type IV
Type V
Type VI
Skin Classification Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Skin Care Professional
Concerns & Treatment Plan
Specific Concerns
*
Type of Treatment
*
Notes / Remarks
Recommended Home Skin Care Products
Daytime Product 1
Daytime Product 2
Daytime Product 3
Daytime Product 4
Nighttime Product 1
Nighttime Product 2
Nighttime Product 3
Nighttime Product 4
Blemishes / Acne
Blemishes / Acne Present
Yes
How many years
Acne Type - Vulgaris
Please Select
Yes
No
Acne Chronic
Please Select
Yes
No
Acne Type - Cystic
Please Select
Yes
No
Other Conditions
Rosacea
*
Please Select
Yes
No
Scars (acne, etc)
Other Skin Concerns
Other (Skin Concerns) - Line 1
Other (Skin Concerns) - Line 2
Other (Skin Concerns) - Line 3
Submit
Should be Empty: