New - Client Skin Analysis
Name:*
Date:*
Age:*
Sex:*
Male
Female
Address:*
City:*
State:*
Zip:*
Known Allergies:
Current Medications:
Skin Classification (Fitzpatrick):*
Type I-Very Pale/Never tans/Always burns
Type II-Pale/Rarely Tans/Burns Easily
Type III-Light/Light Tan/Sometimes Burns
Type IV-Olive/Rarely Burns/Can Tan
Type V-Brown/Rarely Burns/Tans Well
Type VI-Dark/Never Burns/Tans Very Well
Select all applicable skin conditions:*
Normal
Dry
Dehydrated
Mature
Thin/Sensitive skin
Oily
Open pores
Blackheads
Whiteheads
Asphyxiated pores/follicles
Blemishes/Acne
Scars (from acne/etc)
Photoaging
Wrinkles
Superficial lines
Deep lines
Relaxed elasticity
Good elasticity
Any broken capillaries?
Dilated capillaries
Discolorations
Other
If other, please explain:
If acne, how many years?:
What classification(s) of acne?:*
Vulgaris
Chronic
Cystic
Rosacea
Other
Not Applicable