Due to the nature of this form, it can only be filled out on a laptop or desktop computer. 

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Health History Form

Please fill out this to the best of your ability

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Please choose whether you've had any of the following

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Please check off any procedure about which you'd like to receive more information:

SCORE

0

1

2

3

4

What is the natural color of your hair?

What is your eye color?

Sandy Red

Blonde

Chestnut, dark blonde

Dark brown

Black

Light blue, Gray, Green

Blue, Gray, Green

Blue

Dark Brown

Brownish Black

What is the color of sun unexposed skin areas?

Reddish

Very Pale

Pale with beige tint

Light brown

Dark Brown

How many freckles on unexposed skin areas?

Many

Several

Few

Incidental

None

What happens when you are in the sun  TOO long without sunblock?

Painful redness, blistering, peeling

Blistering followed by peeling

Burns, sometimes followed by peeling

Rarely Burns

Never had a problem

How well do you turn brown?

Hardly or not at all

Light color tan

Reasonable tan

Tan very easily

Turn dark very quickly

Do you turn brown within one day of sun exposure?

Never

Seldom

Sometimes

Often

Always

How does your face respond to the sun?

Very sensitive

Sensitive

Normal

Very resistant

Never had a problem

When did you last expose yourself to the sun or artificial sun treatments?

More than 3 months to go

2-3 months ago

1-2 months ago

Less than 1 month ago

Less than 2 weeks ago

Do you expose the area to be treated to the sun?

Never

Hardly ever

Sometimes

Often

Always

TOTAL

00-07 points = Skin type I

08-16 points =  Skin type II

17-25 points = Skin type III

25-30 points = Skin type IV

30-40 points = Skin type V & VI

Thanks for submitting! We now have all health information needed to see you.