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Littlemountainlaser.com

Skin Analysis
Please check all the areas that you are considering for treatment:
Please check the conditions you would like treated:
Have you ever had:
When?____________________________________________________________ Have you used any of these in the last month : Renova, Tazorac, Retin A, Alpha Hydroxy or Glycolic acids?
Have you used Accutane or had radiation therapy?
Are you currently taking any of the following? Tetracycline, Bactrim, Hydrochlorothiazide, St. Johns Wort,
Antibiotics (oral or topical), or any other medication that may make you sensitive to the sun?

___ No ___ Yes – type/location: ____________________________________________________________________ Medication allergies: ________________________________________
In the last 6 weeks have you done any of the following?
___ Tweezing
___ Tanning of any kind ___ None of these How often do you wear sunscreen?
___ Always
Do You Have Any of The Following Conditions:
___ Medical conditions with excessive hair growth Skin Typing Evaluation and Patient Evaluation Form
This information will help our office to better evaluate your skin type so the laser treatment will bemore effective. Skin type is often categorized according to the Fitzpatrick skin type scale, which rangesfrom very fair (skin type I) to very dark (skin type VI). The two main factors that influence skin typeand the treatment program devised by your practitioner are: • Reaction to sun exposure and tanning habits Skin type is determined genetically and is one of the many aspects of your overall appearance, whichalso includes the color of your eyes, hair, etc. The way your skin responds to sun exposure is anotherway of correctly assessing your skin type. Recent tanning, whether by the sun or an artificial tanningbooth, even tanning creams, can have a major impact on your skin color evaluation.
By using the information you provide on this form, we can be better prepared to provide you with thebest care. Please take a few minutes to fill out this questionnaire.
Genetic Disposition
Total score for genetic disposition: _________
Reaction to Sun Exposure
Total score for reaction to sun exposure: _________
8501-00-1695 Revision 04 • Candela Corporation Proprietary Information • December 2001 Tanning Habits
Total score for tanning habits: _________
Summary
Add up the total scores for each section for your Skin Type Score to give you a better evaluation of your skin type.
_______Total score for Genetic Disposition _______Total score for Reaction to Sun Exposure Your Fitzpatrick Skin Type:
Skin Type Score
Fitzpatrick Skin Type
PATIENT SIGNATURE __________________________________________________________ DATE ______________ 8501-00-1695 Revision 04 • Candela Corporation Proprietary Information • December 2001

Source: http://littlemountainlaser.com/PDFs/skineval.pdf

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