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1706 NW Glisan Street, Suite 2, Portland, OR 97209


Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Name :
*Last Name :
Middle Name : *First Name :
One of the important parameters for the success of your treatment is the correct typing of your skin.
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 doctor 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 color of eyes, hair, etc. The way your skin reacts to sun exposure is another important factor in correctly assessing your skin type. Recent tanning (sun bathing, artificial tanning or tanning creams) have a major impact on the evaluation of your skin color. So, help us determine your skin type and treat you the right way.

Genetic Disposition

What is the color of your eyes?
What is the natural color of your hair?
What is the color of your skin (non- exposed area)?
Do you have freckles?
Total score for Genetic Disposition:

Reaction to Sun Exposure

What happens when you stay in the sun too long?
To What degree do you turn brown?
Do you turn brown within several hours after sun exposure?
How does your face react to the sun?
Total score for Reaction to Sun Exposure:

Tanning Habits

When did you last expose your body to sun (or artificial sunlamp/tanning cream)?
Did you expose the area to be treated to the sun?
Total score for Tanning Habits:
Skin Type Score Fitzpatrick Skin Type
0-7 I
8-16 II
17-25 III
26-30 IV
Over 30 V-VI
The Total Skin Type Score :
Fitzpatrick Skin Type :
* I                         attest that I have answered the above to the best of my knowledge.
*Patient Signature