Vitiligo Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *Phone *D.O.BMarital status:MarriedSingleDivorcedWidowHave you ever been diagnosed with vitiligo by a doctor? Yes No How long did/do you have vitiligo?Less than yearMore than yearHow old were you when your vitiligo started (age in years)?Under 13 Over 20 Over 30 Over 40 Over 50 When did your vitiligo start (SPECIFY SEASON)? Summer Winter Fall Does the vitiligo affect both sides of the body?NoYes Not at all How much body surface area does the vitiligo affected? Less than 1% Less than 10%More than 10% What part of your body is affected? Mention if it on both sides or one side only? Scalp One side Both sideHairs/Head One side Both sideEyelids/Eyelashes One side Both sideFace One side Both sideLips/Mouth One side Both sideChest/Breast One side Both sideStomach One side Both sideBack One side Both sideUnderarms One side Both sideArms/Elbow One side Both sideWrist/Hands/Fingers One side Both sideHips One side Both sideGenitals One side Both sideButtocks One side Both sideLegs One side Both sideKnees One side Both sideFeet One side Both sideWhat is your weight (please indicate in pounds )? What is your current height (please indicate in inches)?Where did you grow up for the first ten years of your life? (Please indicate city, state and country)?How often did you go to the beach as a child? Everyday Once a week Once a month Once in blue moon Did you ever have blistering sunburn? NoYes Never If you answered "yes", that you had a previous sunburn, please explain when this occurred? Less than 2 years More than 2 years Have you ever used tooth bleaching products? If so, when? NoYes Not at all Do you now or have you used hair bleaches? NoYes Not at all Please include the years you used hair dye. Which of the vitiligo locations is most bothersome to you?Has any doctor ever told you there is no therapy for vitiligo? NoYes Never Do you have or have you ever had any of these ? Asthma Allergies Eczema Do you have or have you ever had intermittent abdominal cramping? NoYes Don’t know Are you lactose/Gluten intolerant? NoYes Don’t know Did you ever get allergy shots? NoYes Never If yes: Which allergens did you get shots for? Do you have any other autoimmune diseases other than vitiligo? NoYes Never If you answered yes above, please indicate which of these illnesses you had or write in under other: Diabetes (Type 1) Diabetes (Type 1I) Thyroid (Autoimmune )Rheumatoid arthritis Lupus Pernicious Anemia Alopecia Areata Celiac disease Psoriasis Ulcerative Colitis Multiple sclerosisDiabetes (Type 1)Diabetes (Type 1I)Thyroid (Autoimmune )Rheumatoid arthritisLupusPerniciousAnemiaAlopecia AreataCeliac diseasePsoriasisUlcerativeColitisMultiple sclerosisDid you have any stressful life events in the 2 years prior to the onset of vitiligo (e.g. divorce, lost job, etc.)? No Yes Does your vitiligo get worse or spread after stressful events occur? No Yes Not at all Do you have friends with vitiligo (circle one)? No Yes Had a loved one passed away within the 2 years prior to developing vitiligo? No Yes NameSubmit