Sebum Control, overall patient Compliance and Acne Performance Evaluation

Phone Number *

Email * Full Name *

Qualification * Clinic/ Hospital name: * City: * Date of Enrollment * Case No: *

Place pin on the exact location

Deliver To

Detecting address...

Patient Age (in Years) * Patient Gender *

Male Female Other

Clinical Assessment

Acne Type (Tick One) *

Comedonal Acne Papular Acne Pustular Acne Mixed Acne Nodulocystic Acne

Severity Assessment (GAAS) *

Mild Moderate Severe

Skin Type *

Oily Combination Dry Sensitive

Presenting Concerns (Tick all that apply) *

Excess Sebum / Oiliness Inflammatory Acne Lesions Non-Inflammatory Acne Lesions Post-Inflammatory Hyperpigmentation (PIH) Dryness Skin Barrier Damage Enlarged Pores

Treatment Plan

Femcinol Sebrium Gel Usage *

Once Daily Twice Daily

Concomitant Acne Therapy (Tick all that apply) *

Adapalene Benzoyl Peroxide Clindamycin Oral Antibiotics Isotretinoin Other

Clinical Status *

Select one option against each parameter

Parameter	Mild	Moderate	Severe
Excess Sebum
Inflammatory Lesions
Non-Inflammatory Lesions
PIH
Dryness
Skin Irritation

Upload Photo / Capture Photo *

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You can also capture using camera

PNG, JPG or JPEG

Key Clinical Observation *

I hereby declare on behalf of the patient I am authorised to share patient information like image and treatment Details

Brand Preference *

Retailer Name * Retailer Code * City * State *

Full Name (as per PAN Card)

Phone Number

Email

Qualification

Clinic/ Hospital name

City

Date of Enrollment

Case No.

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SEBUM SCPOE PMS STUDY

Deliver To

Clinical Assessment

Treatment Plan

Clinical Status *

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Pan Card

Cancelled Cheque

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