Her Medical Skin type Questionairre

Fitzpatrick skin type scale was developed to measure how skin reacts to ultraviolet light or sun exposure. This helpful scale is used by doctors to gauge certain skin’s reaction to the sun and how to more quickly identify potentially malignant sun spots.

First Name

Last Name

Usual treating Doctor

Skin Check appointment date

Your natural hair colour is? *

Red or light blondeBlondeDark blonde or light brown Dark brown Black

Hair Score

12345

Your eye colour is? *

Light blue, light great or light green Blue, grey or green Hazel or light brown Dark brown Brownish black

Eye Score

12345

Your natural skin colour (before exposure to sun) is? *

Ivory whiteFair or paleFair to beige, with golden undertoneOlive or light brown Dark brown or black

Skin colour score

12345

How many freckles do you have ? *

ManySeveralA fewVery FewNone

Freckles Score

12345

How does your skin respond to the sun? *

Always burns, blisters and peelsOften burns, blisters and peels Burns moderately Burns rarely, if at allNever burns

Burn score

12345

Does your skin tan? *

Not at all or very littleLightlyModeratelyDeeplyMy skin is naturally dark

Tan Score

12345

How sensitive is your face to the sun? *

Very sensitive SensitiveNormalResistant Very resistant / Never had a problem

Sensitivity score

12345

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