FITZPATRICK SKIN EVALUATION

 

Score 0 1 2 3 4 Score

What is the color of your eyes?

 Light blue, gray, Light Green blue, gray or Green Dark Blue or Hazel Dark Brown Brownish Black  
What is the natural color of your hair? Sandy or red Bonde Chestnut /Dark Blonde Dark Brown Black  
What is the color of your skin (non exposed areas) Reddish Very Pale Pale with beige Tint Light Brown Dark Brown  
Do you have freckles on unexposed areas? Many Several Few Incidental None  

Total Score for Genetic Disposition:________________________________

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What happens when you stay in the sun too long?

 Painful redness, blistering, peeling Blistering followed by peeling Burns sometimes followed by peeling Rarely burn Never had burns  
To what degree do you turn brown Hardly or not at all Light color tan Reasonable tan Tans easily Turns dark brown quickly  
Do you turn brown within several hours after sun exposure? Never Seldom Sometimes Often Always  
How does your face react to the sun? Very sensitive Sensitive Normal Very resistant Never had a problem  


Score 0 1 2 3 4 Score

When was the last time you exposed your body to the sun, tanning bed or self-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  
How frequently do you expose the area to be trated to the sun? Never Hardly ever Sometimes Often always  

Total Combined Score:______________
 



ADDRESS

LaserDerm MedSpa

7169 University Boulevard
Winter park, fl 32792

407-678-4884

 

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