Sebum Control, Overall Patient Compliance and Acne Performance Evaluation

Sebum Control, Overall Patient Compliance
and Acne Performance Evaluation

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Phone Number *

Email * Full Name *

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

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Deliver To

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Patient Details

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 *

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Key Clinical Observation

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

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Pan Card

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HCP's Name Name in PAN Card

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Cancelled Cheque

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HCP's Name Name in Cheque

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Brand Preference *

Retailer Name * Retailer Code * City * State *

Full Name (as per PAN Card)

Phone Number

Qualification

Clinic/ Hospital name

City

Date of Enrollment

Case No.

Patient Age

Patient Gender

Acne Type

Severity Assessment

Skin Type

Presenting Concerns

Gel Usage

Concomitant Acne Therapy

Other Acne Therapy

Clinical Status

Excess Sebum -

Inflammatory Lesions -

Non-Inflammatory Lesions -

PIH -

Dryness -

Skin Irritation -

Key Clinical Observation

Patient Photo

DECLARATION

I hereby confirm that the above observations are based on my routine clinical practice and assessment of patients enrolled under the Sebum SCOPE PMS Study.

Doctor Signature & Stamp

Date

23 / 09 / 2026

Disclaimer: This data can be published & can be used for non-commercial purposes.

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