Submit the details of your acne problem

Important: Please read all questions and answer honestly. With more comprehensive and honest answers, treatment quality will increase. After you complete the form, you will be redirected to whatsapp, where you will have to submit clear photo of your acne (both sides of your face, forehead & chin plus chest/back only if there is acne). Photo should be clearly focussed, free from reflection (no flash) or shadow and preferably taken in natural light during day-time.

About you (will be kept private)

Mention your 10 digit WhatsApp no along with country code (total should be 12). If from india, start with 91 (already set)

Please give the WhatsApp number from which you will send the message (installed in this phone). If you have already sent a message before, open the chat directly from WhatsApp.

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Age (in year)

Male Female

Health parameters

Weight (in kg) - if you know it in pound/lbs, divide it by 2.2

Height (Write in inches, for eaxample 5'6'' = 66 inches)

Waist (Size of jeans)

Select associated features if present. 'Female only' options are applicable only if you are a female.

Select health condition, if present None Dry skin Irritancy prone (sensitive) skin Past use of steroid cream (e.g betnovate, panderm, lobate etc) over face Redness Photosensitivity (sun allergy) Acanthosis nigricans (dark neck) Unwanted hair over face (female only) History / presence of PCOD (female only) Mainly comedonal lesion (whiteheads & blackheads) High level of psychological stress due to acne Dandruff on scalp Irregular period (female only) increased acne before or during period (female only) Presence of post inflammatory hyperpigmentation (PIH)

Select health condition, if present. 'Female only' options are applicable only if you are a female.

None Pregnency (female only) Breast feeding now (female only) Smoking habit Low blood pressure High blood pressure Diabetes Increased cholesterol in blood Liver diseases Cardiac arrythmia (conduction problem in heart) Heart diseases (other) Migraine History of breast cancer (past/family) History of vascular / thrombotic event such as stroke or heart attack Bed ridden patient Kidney disease Reduced potassium level in blood (or on potassium lowering drug already) Depression or on anti-psychotic drug SLE (diagnosed with LUPUS) Myasthenia gravis Porphyria Colitis Asthma Peptic ulcer Immunocompromised state (such as HIV , on systemic steroid due to other problem or uncontrolled diabetes)

Choose medications to be excluded from the recommendation due to allery, intolerance, previous failure or any other reason like cost or availability.

None Isotretinoin Doxycycline Azithromycin Metformin Spironolactone OCP (oral contraceptive pill) Benzoyl peroxide (topical) Topical retinoid Topical antibiotic

Lab report (if available, otherwise keep blank).

If you are filling these fields, make sure the unit matches with your report as well.
Fasting glucose (mg/dl)

Fasting insulin level (micro U/ml)

Only for female

DHEA-S (microgram/l)

Prolactin (ng/ml)

Total testosterone level (ng/dl)

Free testosterone level (pg/ml)

Serum FSH (micro IU/ml)

Serum LH (micro IU/ml)

AMH (ng/ml)