Name : Age : Gender : Male Female Address : Country : Landline No. : Mobile No. : E-mail ID : Fax No. : Present problem in detail History of Present Disease : Onset : when did the problem start/ duration : Sites of involvement/ Areas affected : Symptoms: eg. itching/ pain /redness/ rashes : Progression of disease (Has the nature of symptoms changed?) : Provocative factors: Heat, cold, sunlight, exercise, drug ingestion : Any seasonal change or day /night variation : Treatment history & response to it : Past/Concomitant Medical History Allergy (to drugs or anything else) : Any other problem like diabetes or hypertension : Medical history/ Any chronic medicinal intake : Habits (smoking, alcohol or drug abuse) : Family History History of any similar illness in family members : History of any other significant problems e.g. asthma, rhinitis : Kindly attach a few close up photographs of your problem area :