Client Skin Analysis/Evaluation Form
Name:________________________________________________________ Date of Consult: ___________________
Address: _____________________________________________________
City:________________________________________________________
Age:__________ Gender:___________
State:_________________
Zip:________________
Known Allergies:__________________________________________________________________________________
Medications:______________________________________________________________________________________
Fitzpatrick Classification: Type I
Skin Classification
Type II
Type III
Type IV
Type V
Type VI
Normal_______________________________________
Scars (acne, etc)_______________________________
Dry___________________________________________
Photoaging____________________________________
Dehydrated___________________________________
Wrinkles______________________________________
Mature_______________________________________
Superficial lines________________________________
Thin, sensitive skin_____________________________
Deep lines____________________________________
Oily__________________________________________
Relaxed elasticity_______________________________
Open pores___________________________________
Good elasticity_________________________________
Comedones (blackheads)________________________
Couperose (broken capillaries)___________________
Milium (whiteheads)_____________________________
Dilated capillaries_______________________________
Asphyxiated (blocked pores and follicles)____________
Discolorations_________________________________
Blemishes/Acne________________________________
Other: _________________________________________________
How many years?___________________________
_______________________________________________________
Vulgaris: m No m Yes
Chronic: m No m Yes
_______________________________________________________
Cystic: m No m Yes
Rosacea: m No m Yes
_______________________________________________________
Date:___________________
Skin Care Professional:___________________________________________________
Specific Concerns:________________________________________________________________________________
Type of treatment:_________________________________________________________________________________
Notes/Remarks:__________________________________________________________________________________
Recommended Home Skin Care Products:
For Daytime:For Nighttime:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
member
Associated Skin Care Professionals