Name of Doctor *

Registration No. *

Qualification *

Speciality *

City *

State *

State *

Initials *

OPD/IPD Registration No *

Age (in Years) *

City/Town *

State *

State *

Pulse (per minute)

Blood Pressure: Systolic (mmHg)

Diastolic (mmHg)

Weight (in Kg)

Height (in cm)

Body Mass Index (BMI) (kg/m²)

Skin type

Dry Oily Acne prone Hyper pigmented

Duration of the diseased condition:

Less than 1 month 1-<3 months 3-<6 months >6 months

Severity of the condition

Mild Moderate Severe

Family History

H/O co-morbidities

Polycystic Ovary Syndrome (PCOS)

Yes No

Addison disease

Yes No

Atopic dermatitis

Yes No

Psoriasis

Yes No

SAHA(Seborrhoea, Acne, hirsutism, Alopecia) syndrome

Yes No

Any other co-morbidity

Yes No

H/o any medication that can cause Acne

Yes No

H/O treatment taken for the current condition (if any)

Sunscreen

Yes No

Any specific medication prescribed

Yes No

Any procedure done

Yes No