SPF Subject Questionnaire

  1. Are you currently pregnant or nursing?    Yes*____ No ____
  2. Participants must be between 18 – 70 years old. Are you within this age range?   Yes ____ No*____
  3. After a winter season of no sun exposure, how would your skin react to the first 30 to 45 minutes of sun exposure? Check one type only.


Always burns easily; never tans (sensitive).



Always burns easily; tans minimally (sensitive).



Burns moderately; tans gradually (light brown) (normal).



Burns minimally; always tans well (moderate brown) (normal).



Rarely burns; tans profusely (dark brown) (insensitive).



Never burns; deeply pigmented (insensitive).

  1. Have you used a sunlamp or tanning parlor within the last 3 months?  

Yes*____ No ____

  1. Have you participated in a clinical study within the last month?  

Yes*____ No ____

  1. Are you in good general health?     Yes ____ No*____

If no, explain ___________________________________________________

  1. Are you taking medications regularly?     Yes ____ No ____

If yes, list medications (Include Dosage and Indication) ____________________________________________________


  1. List all medications taken within the last week (Including Dosage and Indication):



  1. Are you using any compounds on (see Protocol-15) the Prohibited Photosensitizing Compound list? Read the subject the categories /compounds on the list.   Yes*____ No ____
  2. Do you have an abnormal response to UV radiation?  Yes*____ No ____
  3. Do you have a sensitivity to sunscreens? Yes*____ No ____
  4. Do you have a sensitivity to topical products?   Yes*____ No ____
  5. Do you have a history of psoriasis, atopic dermatitis, skin cancer, dysplastic nevi or other skin pathology?           Yes*____ No ____
  6. Do you have scars?              Yes*____ No ____
  7. Do you have active dermal lesions?         Yes*____ No ____
  8. Do you have uneven skin tone?      Yes*____ No ____
  9. Do you have Nevi, Blemishes, or Moles? Yes*____ No ____

These will be acceptable if, in a physician’s judgment, they will neither compromise the study nor jeopardize the subject’s safety.

  1. Do you have a history of any other condition which might interfere with the test or increase the risk of participation?          Yes*____ No ____

If yes, explain ___________________________________________________

  1. Do you have transportation? We are located in Eagan, MN.   Yes*____ No ____
  2. What days and times would you be available?

Monday     Tuesday     Wednesday Thursday    Friday   …

  1. Due to equipment limitations, subjects whose weight exceeds 300 lbs. may not participate in SPF tests. Are you over 300 lbs.?   

Yes*____ No ____

Study Exclusion*

Findings:  Eligible _______               Not Eligible: _______

Record reason for subject disqualification if applicable:


Technician                                                        Date