Fitzpatrick Skin Type Questionnaire (Circle the one that best describes you under each category)Genetic DispositionWhat best describes your eye color? Light Blue, Gray Green Blue Brown Dark Brown What is your natural hair color? Red Blonde Chestnut, Dark Blonde Dark Brown Black What is the color of your skin (non-exposed areas)? White Very Pale Pale with a Beige Tint Light Brown Dark Brown Do you have freckles on unexposed areas? Many Several Few Incidental None Reaction to Sun Exposure:What happens when you stay in the sun? Painful redness, blistering, peeling Blistering followed by peeling Burns sometimes followed by peeling Rare burns Never had burns To what degree do you brown? Hardly or not at all Light color tan Reasonable tan Tan very easily Turn dark brown very 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 Tanning Habits:When did you last expose your body to the sun or artificially tan? More than 3 months ago 2 to 3 months ago 1 to 2 months ago Less than a 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:Skin Type Score: Fitzpatrick Skin Type: 0 to 7 I 8 to 16 II 17 to 25 III 26 to 30 IV Over 31 V-VI I attest that the above information is true and understand that my provider relies on this information to provide safe and effective treatment. Δ
