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Client Skin Analysis Evaluation Form
First Name
Last Name
Address
Known Allergies
Medications
Skin Classification
Fitzpatrick Classification:
Type I
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
Yes
No
Chronic
Yes
No
Cystic
Yes
No
Rosacea
Yes
No
Select a date
Skin Care Professional
Specific Concerns
Type of treatment
Notes/Remarks
Recommended Home Skin Care Products
For Daytime
For Nighttime
Submit
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