doi:10.1841 0/jebmh/2015/1176 40. Rohit V, Gajula N. Role of Intralesional Measles Mumps Rubella Vaccine in Cutaneous Warts : A Case Control Study. 2017;(December):57 -60. 33 ANNEXURES Department of Dermatology and V enereology BPKIHS, Dharan Proforma for Wart patients SN: Group: OPD/Inpatient no: Date: Name Age (years): Sex: Race/ethnicity: Education: Occupation: Address: Phone no. History: 1) Duration of wart: 2) Type of wart: 3) Site of lesions: Scalp/Face/Neck/Trunk/Upper extremities/Lower Extremities/ Palms/soles/finger/ toes 4) Number of Lesions at presentation: 5) Size of lesion: 6) Progression of lesion: Gradual/Rapid/Stable/ Regressing 7) Any associated Symptoms: Pruritus: n one/ mild/ moderate/ severe Pain: none/ mild/ moderate/ severe Burning sensation: none/ mild/ moderate/ severe 8) Associated personal Systemic illness: Yes/No If yes: HIV/ Diabetes/ Asthma/ Allergic skin disorders/ Convulsion / bone pain/ muscle weakness 9) Pregna nt/ lactating mother: Yes/No/ N A 10) Taking any other drugs: Yes/No If yes: Corticosteroids/ Immunosuppressive/ Others 11) Past treatment taken: Yes/ No If yes: Self -care (Herbs/ Drugs/ Bought from pharmacy) Traditional (Traditional healer/ Herbalist/ Other) Seek medical help or treatment (Topical/ Systemic/ Both/ Surgical) Improvement: Worse/ No/ Mild/ Moderate/ Good Time since last trea tment: Reason for treatment: 34 Treatment given: IL MMR/ IL Vitamin D Response to treatment Number of visits Date Percentage decrease from baseline Percentage decrease from last visit Side effects (pain ,redness, edema, Infection, scarring, ulcer, pigmenta ry changes, flu like symptoms, anaphylaxis , confusion, polyuria, polydipsia, anorexia, nausea, vomiting, muscle weakness, bone pain, altered sensorium) Remarks (Vitamin D level 20 days after 3rd visit, 1 month after last dose) 1st 2nd 3rd 4th 5th Follow Up Number of visits Date Percentage decrease from baseline Recurrence (Yes/No) Remarks 6th 7th 8th 35 36 Department of Dermatology and Venerology BPKIHS, Dharan , Nepal Patient Information Sheet I Dr. Bibisha Baaniya , Junior Resident of Dep artment of Dermatology and Venereology at B.P .