ID Patient Name Hospital age occupation
sex socieoecomenic status phone number religion Area
Darkness of the skin duration onset site of distribution temples
Weight gain weight gained durations lethargy increased sweating
hematemesis Increased hair growthdiabetes mellitus mediciation duratio
similar complients treatment taken others darkening of skin
maliganancy in the family
any associated skin diet sleep habits apetite
bladder physcal activity age of menarche menestrual cycles flow
pallor pulse rate bp height weight
bmi waist circumfernacehip circumfernace waist neck severity
Axilla neck texture knuckles elbows knees
acne acrochordon bacterial infections fungal infections striae distansae
hirsuitism androgenic alopeciaseborrheic keratosis others1 cardiovascular system
respiratory system per abdomen central nervous system
serum insulin fasting
serum
ptient
insulin fasting ref value
serum insulin pp pvserum insulin pp rv
Blood sugar fasting Blood
PV sugar fasting
Blood
RVsugar Post prandial PV
Blood sugar Post prandialLP
RVTotal Chol PV LP Total Chol RV LP triglyceradies PVLP triglyceradies RV
LP HDL PV LP HDL RV LP VLDL PV LP VLDL RV LP LDL PV
LP LDL RV LP CHOL HDL PV LP CHOL HDL RV TREATMENT
ID Patient Na Hospital age occupationsex socieoecomphone numreligion
presentingduration age of onsedandruff seasonal vanature of sacne mechtopical sterpowder
shampoo soap others use of bur cream oil parlour pr home remegym
use of burkmobile usasmoking previous orother oral social phobany sympt food drinks
juice and cfired itemsimpressionpast histor age of menheavyor scpremestural
bladder sleep
pallor Vitals puls BP Height RR Temp Weight ex nature osite
lesions of pattern of dassociated scares other findi evidence ofgrade of a nails scalp
begin com begin papubegin pustubegin nodubegin cystsbegin perce2 Weeks c 2 Weeks pa2 Weeks pu
2 Weeks no2 Weeks cy2 Weeks pe4 Weeks c 4 Weeks pa4 Weeks pu4 Weeks no4 Weeks cy4 Weeks pe
8 Weeks c 8 Weeks pa8 Weeks pu8 Weeks no8 Weeks cy8 Weeks pe12 Weeks 12 Weeks p12 Weeks p
12 Weeks n12 Weeks c12 Weeks pSensitive Resistat question 1 Question 2Question 3Question 4
Question 5Forehead Right cheeLeft CheekNose Chin Chest and upper back
ID Name of paAge OccupationAddress OPD No opd Date case no Hospital
Socio econmarital staOnset Site of set progressio provoking fpruritis cosmetic hihisotory of
any ho simany topicalany ho dia any similarho atopy indiet bowels appetite bladder
sleep habits Built and pallor lymphadenpulse rate bp temp rr
mucous mehair nails Dist lesion Dist lesion Dist lesion site Type of lessecondary
any other fcvs rs cns git clinical dia histopathollab no epidermal
dermal chaother chanhistopatholfinal diagnosis
ID Case no Patient Na Age Sex Address Phone Occupationpresenting
duration ill site predo currently oExzema Evolution aAggravatioAtopy histopartheniumcement
detergent new footweshampoo na
printing a tropical meantibactieribleach lesion aroutextile indu
rubber induleather indearrins polish antiper pharma hairdye Others past histor
treatment morphologconfiguratidistributionprovisionalexpected allergens
ID Patient Na Age Sex Sl no Address IP or OP NoOccupationInformant
rec Date Parents oc Over crowdHistory of PMode of onCourse symptoms itching intensity
diurnal varDistributio seasonal vaSweating Skin lesionTopical prolonged s ystemic associated
triggers others past histor Past histor Family histFamily histdiet teething crhabits
playing habimmunisatiappetite sleep bowel and usage of s usages of dNourshimen
mucus
eyes hair nails weight pulse bp rr distributio site
morphologprimary lesMargins Surface colour config secondary scales crusts
scarring hairs sensation regional l triple resonsystemic ecvs cns rs
pa provisional diagnosis
ID Name : Age : Sex : OP No : Address : OccupationReligion : Ph No :
Date : Diagnosis aMode of Det
Previous TrPatient StaContact HisContact HisContact1 Sex1 :
Age1 : Relation toContact2 : Sex2 : Age2 : Relation toContact3 Sex3 : Age3 :
Relation toContact4 Sex4 : Age4 : Relation toHypopigmen
Others Profession Living Cond
SES Diet Gynaec HisFamily HistPast HistorGait Ht Wt SKP numbe
SKP DescriSKP SensatSKP FeedinPN Supra Or
PN Supra Or
Infra OrbitaInfra OrbitaPost AuricuPost Auricu
Supra ClaviSupra ClaviGreater AurGreater AurRadial R Radial L Ulnar R Ulnar L Median R
Median L Radical Cu Radical Cu Commin Per
Commin Per
Posterior TPosterior TSural Nerv Sural Nerve L
Sural Nerve L
ID Patient na Dates Phone Age sex marrital st occupationhours of e
Religion Chief CompDurations HO Aopy durgs cosmetics previous t steriods associated
gynae hist onset progressio factors initial site distributionmucous mehair nails
lymph nod site arrangemeBorders surface colour sensations temperaturhair over l
sweat reacblood vessereaction toreaction toexaminatiocolour of p Distributio Type of pi Atrophy
TelangiectaPerifollicuaAreas of p other findi woods lamDiagnosis Tretment
ID NPRPRF1 NPRPRF2 NPRPRF3 NPRPRF4 NPRPRF5 NPRPRF6 NPRPRF7 NPRPRF8
1 334 Follow-up oMale Single 45 15
2 22 0
3 10 0
4 0 0
NPRPRF9 NPRPRF10aNPRPRF10bNPRPRF10cNPRPRF10dNPRPRF11 NPRPRF12 NPRPRF13 NPRPRF14a
Yes 0
aa aaa
NPRPRF14bNPRPRF14cNPRPRF14dNPRPRF15 NPRPRF16 NPRPRF17 NPRPRF18 NPRPRF19 NPRPRF20
NPRPRF21 NPRPRF22 NPRPRF22 NPRPRF23 NPRPRF23 NPRPRF24 NPRPRF24 NPRPRF25 NPRPRF25
Not Known
NPRPRF26 NPRPRF26 NPRPRF27 NPRPRF27 NPRPRF28 NPRPRF28 NPRPRF29 NPRPRF29 NPRPRF30
NPRPRF30 NPRPRF31 NPRPRF31 NPRPRF32 NPRPRF32 NPRPRF32 NPRPRF32 NPRPRF32 NPRPRF32
NPRPRF32 NPRPRF32 N
i PRPRF33 NPRPRF34 NPRPRF34 NPRPRF34 NPRPRF34 NPRPRF35 NPRPRF35
0 None
NPRPRF35 NPRPRF35 NPRPRF36 NPRPRF36 NPRPRF36 NPRPRF36 NPRPRF37 NPRPRF38 NPRPRF38
NPRPRF38 NPRPRF38 NPRPRF39 NPRPRF40 NPRPRF40 NPRPRF40 NPRPRF40 NPRPRF40 NPRPRF40
NPRPRF41 NPRPRF41 NPRPRF41 NPRPRF42 NPRPRF42 NPRPRF42 NPRPRF43 NPRPRF43 NPRPRF43
NPRPRF44 NPRPRF44 NPRPRF44 NPRPRF45 NPRPRF45 NPRPRF45 NPRPRF46 NPRPRF46 NPRPRF46
NPRPRF47 NPRPRF47 NPRPRF47 NPRPRF48 NPRPRF48 NPRPRF48 NPRPRF49 NPRPRF49 NPRPRF49
NPRPRF50 NPRPRF50 NPRPRF50 NPRPRF51 NPRPRF51 NPRPRF51 NPRPRF52 NPRPRF52 NPRPRF52
NPRPRF53 NPRPRF53 NPRPRF53 NPRPRF54 NPRPRF54 NPRPRF54 NPRPRF55 NPRPRF55 NPRPRF55
NPRPRF56 NPRPRF56 NPRPRF56 NPRPRF57 NPRPRF57 NPRPRF57 NPRPRF58 NPRPRF58 NPRPRF58
NPRPRF59 NPRPRF60 NPRPRF60 NPRPRF60 NPRPRF60 NPRPRF60 NPRPRF60 NPRPRF60 g
ID ExaminatioPhone No Name of PaAge Sex OccupationReligion Hours of S
1 2.11E+08 0 0
2 2323233 0 0
SES1 SES2 SES3 SES4 Cosme
SES 5 PrevSES 6 UsagAssociated Gynaec HisOnset
0
0
Progressio Factors Initial Site Distributio Mucous MeHair Nails Lymph NodSite
ArrangemeBorders Surface Colour SensationsTempratur Hair over l Sweat reacBlood vesse
reaction toreaction tosystemic eColour of pdistributi type of pigatrophy teangiectasperifollicul
areas of i other findi woods lamdiagnosis treatment
ID Patient Na IP or OP NoAge Sex Address Occupationudate phone
chief complonset pruritus duration arthralgia precipitati drugs infection past histor
menstual hifamily hist personal hidiet habit built hair edema pallor
distributionlymph nod nails mucous mecyanosis any eczemtwhite dem cvs ent dental
rs pa thyriod gynac blood hb blood tc blood dc blood esr blood absol
urine stool fbs ppbs ice cube tetestfor de other invesliver functi biopsy
treatment o weeks 2 weeks 4 weeks sev 0 sev 1 sev 2 sev 3