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HomeSkin Care Protocol

Skin Care Protocol

Skin Protocol Form

Skin Protocol Form

Skin Issue Management form

Case Details (SMF)

Patient Name

UPID

Contact Number

Email ID

Consultation Date

Consultant Name

Healthcoach Name

Age (yrs)

Body weight (kg)

Height (cms)

BMI

Discolouration - bluish/reddish

Itching

Swelling

Dry & Rough skin

Coarse skin & scaling

Cracking sensation

Burning sensation

Sweating

Moisture over affected area

Discharge

Pus Formation

Paleness -generalised or localised

feel of coldness

Rigidity of skin

localised heaviness

Generalised heaviness

Painful skin lesions

Sensation altered/numbness

Dosha Predominance

Associated complaints

Aggravating factors

Relieving factors

Past Medical History

HTN

DM

THYROID

NO ANY

Family History
yes no

Agni
Vishamagni Tikshnagni Mandagni Samagni

Gastric trouble

Bloating

Pass with ease

Pass with difficulty

Burps

No

Acidity

Heartburn

Reflux

Sour belching

No

Bowel frequency

Bowel consistency
Hard soft loose sticky

Bowel evacuation
complete Incomplete

Taking any laxative
yes no

urine
normal Frequent reduced flow Burning urgency Dribbing

Kostha

Sattva

stress

Sleep

sleep timings
Timely Untimely

Menstrual History
NA regular delayed earlier Menopause

Treatment History

Diet

Addiction

Alcohol

Smoking

Tobacco

Tea

Coffee

other

No any

Investigation result if done

Nadi pratikshan

Daily routine

Ayurvedic diagnosis

Modern diagnosis

PASI SCORE

Line of treatment

Affected skin region pics/ reports Choose a file

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