OOPS, YOU SHOULD’T BE HERE……ENSURE YOU BOOK IN FOR A PATCH TEST AND THEN WE’LL COMPLETE THIS FORM TOGETHERLASER TREATMENT FORM - INTERNAL USE ONLY NAME First Name Last Name TATTOO / AREA / HAVE YOU HAD LASER BEFORE? GENETIC DISPOSITION EYE COLOUR 0 = LIGHT BLUE / GREY 1 = BLUE / GREEN 2 = HAZEL / LIGHT BROWN 3 = BROWN GENETIC DISPOSITION NATURAL HAIR COLOUR 0 = PLATINUM / RED 1 = BLONDE 2 = MOUSEY BROWN / LIGHT BROWN 3 = BRUNETTE 4 = BLACK GENETIC DISPOSITION NATURAL SKIN TONE 0 = LIGHT BLUE VEINS 1 = VERY PALE 2 = BEIGE TINT 3 = LIGHT BROWN 4 = DARK BROWN GENETIC DISPOSITION FRECKLES 0 = MANY 1 = SEVERAL 2 = FEW 3 = INCIDENTAL 4 = NONE GENETIC DISPOSITION TALLY SUN EXPOSURE OVER EXPOSURE 0 = PAINFUL BLISTERING 1 = BLISTERING THEN PEELING 2 = BURN SOMETIMES THEN PEELING 3 = RARELY BURN 4 = NEVER BURN SUN EXPOSURE TO WHAT DEGREE DO YOU TAN 0 = NEVER TAN 1 = VERY LIGHT TAN 2 = REASONABLE TAN 3 = DEEP TAN 4 = VERY DARK TAN EASILY SUN EXPOSURE DO YOU DEVELOP A TAN AFTER A COUPLE OF HOURS? 0 = NEVER 1 = NOT OFTEN 2 = SOMETIMES 3 = OFTEN 4 = ALWAYS SUN EXPOSURE HOW DOES YOUR FACE REACT TO THE SUN 0 = VERY SENSITIVE 1 = SENSATIVE 2 = NORMAL 3 = NEVER HAD A PROBLEM 4 = VERY RESILIENT SUN EXPOSURE TALLY TANNING HABITS WHEN DID YOU LAST EXPOSE YOUR BODY TO EXTENDED SUN OR TANNING BOOTHS 0 = MORE THAN 3 MONTHS 1 = 2-3 MONTHS AGO 2 = 1-2 MONTHS AGO 3 = LESS THAN 4 WEEKS 4 = LESS THAN 2 WEEKS TANNING HABITS WHEN DID YOU LAST EXPOSE THE AREA BEING TREATED TO SUN / TANNING 0 = NEVER 1 = HARDLY EVER 2 = SOMETIMES 3 = OFTEN 4 = ALWAYS TANNING HABITS TALLY SKIN SCALE ASSESSMENT TOTAL I = 0-7 II = 8-16 III = 17-26 IV = 26-30 V = 30+ not suitabe MEDICAL DISCLOSURE MEDICATION TAKEN IN THE LAST 6 MONTHS Thank you!
