Alkem

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A Clinical Overview of cutaneous inflammatory disorders in India: The COMET study

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Diagnosis *

Atopic Dermatitis Psoriasis Vitiligo Alopecia

Patient's Age (years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Duration since onset of disease *

Months Years

Seasonal Variation *

Yes No

Before Treatment
After Treatment

Before Treatment
After Treatment

Before Treatment
After Treatment

Before Treatment
After Treatment

Medical History *

Family history of skin diseases Known allergies

Previous occupational exposure Any previous medical conditions

Complaint of depression or anxiety

Lifestyle Suggested *

Dietary advice

Stress reduction

Exercise

Any Other

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