Skin typing questionaire for all devices



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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, green, or gray

Blue, gray or green

Blue

Dark Brown

Brownish Black

Natural color of your hair?

Sandy, red

Blond

Chestnut/ Dark Blond

Dark Brown

Black

Color of your non-exposed skin

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: ________



Reaction to Sun Exposure

Score


0

1

2

3

4

What happens when you stay too long in the sun?

Painful redness, blistering, peeling

Blistering, followed by peeling

Burns sometimes, followed by peeling

Rarely burns

Never burn

To what degree do you turn brown?

Hardly or not at all

Light color tan

Reasonable tan

Tan very easy

Turn 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


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 than 3 months ago

2-3 months ago

1-2 months ago

Less than one month ago

Less than 2 weeks ago

Did you expose the area to be treated to the sun?

Never

Hardly ever

Sometimes

Often

Always


Total score for tanning habits: _______

Summary

Add up the total scores for each section for your Skin Type Score 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

Your Fitzpatrick Skin Type:

Skin Type Score

Fitzpatrick Skin Type


0-7

I


8-16

II


17-25

III


25-30

IV

Over 30


V – VI


NAME: _____________________________________________________ DATE: __________________

COMMENTS: _________________________________________________________________________



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0920-23-0209 Revision 01 Candela Corporation Proprietary Sheet of



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