| Name:
____________________________________________________________________________ |
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| Please answer the
following questions by circling the number which
best describes you. |
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| your clinician
will total your score during the consultation. |
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| My ethnic origin
is: |
Very fair(Scandinavian) |
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_________ |
| Closest to: |
Fair-Skin Caucasians with
light hair and light eyes |
_________ |
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Pale-Skinned Caucasians with
dark hair and dark eyes |
_________ |
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Olive-Skinned(mediterranean,
some Asian or Hispanic) |
_________ |
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Dark-Skinned(middle Eastern,
Hispanic, Asian) |
_________ |
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Very dark-skinned (african) |
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_________ |
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| My eye Color is: |
Light Blue |
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0 |
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Blue / Green |
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1 |
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Green / Gray / Golden |
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2 |
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Hazel / Light brown |
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3 |
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Brown |
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4 |
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| My natural hair
color |
Red |
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0 |
| at 18 was: |
Blonde |
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1 |
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Light brown |
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2 |
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Dark brown |
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3 |
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Black |
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4 |
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| The color of my
skin that |
Pink to reddish |
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| is not normally
exposed |
Very pale |
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1 |
| to sun is: |
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Pale with a beige tan |
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2 |
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Light brown |
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3 |
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Medium to dark brown |
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4 |
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Dark brown to black |
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5 |
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| If I go out into
the sun fo |
Burn, blister and peel |
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0 |
| an hour or so
without |
Burn, then when burn resolves
there is no color change |
1 |
| sunscreen and
have not |
Burn, but then turns to tan
in a few days |
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2 |
| been out in the
sun for |
Gets pink, but then turns to
tan quickly |
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3 |
| weeks, my skin
will: |
Just tan |
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4 |
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Just gets darker |
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5 |
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My skin color is so dark I
can't tell |
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6 |
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| When was the last
time the |
Longer than one month ago |
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| area to be
treated was exposed |
Within the past month |
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1 |
| to natural
sunlight, tanning booths |
Within the past two weeks |
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2 |
| or artificial
tanning creams? |
Within the past week |
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3 |
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If you Score is: |
Your Skin Type is: |
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TOTAL SCORE: |
_________ |
| 00 - 3 |
1 |
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| 00 - 7 |
2 |
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| 00 - 11 |
3 |
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| 012 - 15 |
4 |
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| 16 - 19 |
5 |
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| 20 - 24 |
6 |
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