Health sheet

    Personal information

    RegularIrregularInactive

    YesNo


    Which one?

    YesNo


    Which one?

    YesNo


    Which one?

    YesNo

    YesNo


    Which one?

    YesNo


    Which one?


    HirsutismHypertrichosisAlopeciaMenstrual disturbancesothers


    SpotsScarsEczemasWartsCystsForúnculosBumpsVitiligoPsoriasisAcneNevus


    In which area?

    YesNo


    PorphyriaErythema PoliformusSolar UrticariaLupus

    YesNo


    Which one?

    YesNo


    Where?

    YesNo


    Which one?

    YesNo


    Which one?

    YesNo

    YesNo


    Where?