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 Fitzpatrick
phototype - Sun-reactive skin classifications
Skin Typing Evaluation and Patient Evaluation Form
This information will help our office to better evaluate
your skin type so the laser treatment will be more effective.
Skin type is often categorized according to the Fitzpatrick
skin type scale, which ranges from very fair (skin type
I) to very dark (skin type VI). The two main factors
that influence skin type and the treatment program devised
by your practitioner are:
- Genetic disposition
- Reaction to sun exposure and tanning habits
Skin type is determined genetically and is one of the
many aspects of your overall appearance, which also
includes the color of your eyes, hair, etc. The way
your skin responds to sun exposure is another way of
correctly assessing your skin type. Recent tanning,
whether by the sun or an artificial tanning booth, even
tanning creams, can have a major impact on your skin
color evaluation.
By using the information you provide on this form,
we can be better prepared to provide you with the best
care. Please take a few minutes to fill out this questionnaire.
Genetic Disposition
| SCORE |
0 |
1 |
2 |
3 |
4 |
| Your natural eye color? |
Light blue,greenor gray |
Blue,grayor green |
Blue |
Darkbrown |
Brownishblack |
| Natural color of your hair? |
Sandy,red |
Blond |
Chestnut,dark blond |
Darkbrown |
Black |
| Color of your non-exposed skin? |
Reddish |
Very pale |
Pale withbeige tint |
Light brown |
Darkbrown |
| Do you have freckles on non-exposed
area? |
Many |
Several |
Few |
Incidental |
None |
Total Score for Genetic Disposition___________
Reaction to Sun Exposure
| SCORE |
0 |
1 |
2 |
3 |
4 |
| What happens when you stayToo long in the sun? |
Painful redness, blistering, peeling |
Blistering,followed by peeling |
Burn sometimes followed by peeling |
RarelyBurn |
Neverburn |
| To what degree do you turn brown? |
Hardly, or not at all |
Light color tan |
Reasonabletan |
Tan veryeasy |
Turn dark brown |
| Do you turn brown within several hours after sun
exposure? |
Never |
Seldom |
Sometimes |
Often |
Always |
| How does your face react to the sun? |
VerySensitive |
Sensitive |
Normal |
Very Resistant |
Never had a problem |
Total Score for Reaction to Sun Exposure___________
Tanning Habits
| SCORE |
0 |
1 |
2 |
3 |
4 |
| When did you last expose your body to sun or tanning
booth/cream? |
More than3 months ago |
2 - 3 months ago |
1 - 2months ago |
Less than1 monthago |
Less than 2 weeks ago |
| Did you expose the area to betreated to the sun? |
Never |
Hardlyever |
Sometimes |
Often |
Always |
Total Score Tanning Habits _________
Summary
Add up the total scores for each section for your skin
type to give you a better evaluation of your skin type.
______ Total Score for Genetic Disposition
+______ Total Score for Reaction to Sun Exposure
+______ Total Score for Tanning Habits
=______ Skin Type Score
Skin Type Score Fitzpatrick Skin Type
0-7 ------> I
8-16 ------> II
17-25 ------> III
25-30 ------> IV
Over 30 ------> V - VI
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