Alkem

Patient code (Do not write name here) *

Date *

Patient's Age (years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Primary Diagnosis/Reason for Visit *

{{-- * --}} Other Dermatological Conditions

Skin Type *

Dry Oily Combination Sensitive Normal

Duration since onset of symptoms *

Months Years

Seasonal Variation *

Yes No

Severity of Condition *

Mild Moderate Severe

Type of Moisturizer Prescribed *

Emollient Humectant Occlusive Ceramide based Combination

Formulation *

Cream Lotion Gel

Reason for Prescription *

Hydration Barrier repair Adjunctive therapy

Instructions for Use

Frequency of use*

Once daily Twice daily Any Other

Clinical Response (after 3 months treatment) *

Improvement No change Deterioration

Adverse Reactions *

Yes No

Additional Recommendations *

Sunscreen use Avoidance of irritants Lifestyle modifications Any other

BASIC DETAILS