Please answer the following questions by circling the number which best describes you. Your clinician will total the score during the
My ethnicity is closest to:
I. Very fair (Celtic and Scandinavian)...II. Fair-skinned Caucasians with light hair and light eyes....III. Pale-skinned Caucasians with dark hair and dark eyes...IV. Olive-skinned (Mediterranean, some Asian, some Hispanic...V. Dark-skinned (Middle Eastern, Hispanic, Asians, some Africans)...VI. Very dark-skinned (African)...
2. My eye color is:
Light Blue. (0)
Blue/Green (1)
Green/Gray/Golden (2)
Hazel/Light Brown. (3)
Brown (4)
3. My natural hair color at age 18 was:
Red. (0) Blonde. (1) Light Brown. (2) Dark Brown (3) Black (4)
4. The color of my skin that is not normally exposed to the sun is:
Pink to Reddish. (0)
Very Pale. (1)
Pale with a Beige tint (2)
Light Brown. (3)
Medium to Dark Brown. (4)
Dark Brown/Black. (5)
5. If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will:
Burn, blister and peel. (0) Burn. when the burn resolves there is little.or.no change. (1) Burn, but turns to tan in a few days (2) Get pink, but turns to tan quickly. (3) Just tan. (4) Just gets darker. (5) My skin color is so dark I can't tell (6)
6. When was the last time the area to be treated was exposed to natural sunlight, tanning booths, or artificial tanning cream?
Longer than one month ago. (0) Within the past month (1) Within the past two weeks (3) Within the past weeks (4)