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 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *D.O.BMarital status:MarriedSingleDivorcedWidowHave you ever been diagnosed with vitiligo by a doctor? YesNo How long did/do you have vitiligo?Less than yearMore than yearHow old were you when your vitiligo started (age in years)?Under 13Over 20Over 30Over 40Over 50When did your vitiligo start (SPECIFY SEASON)? SummerWinterFallDoes the vitiligo affect both sides of the body?NoYesNot at allHow much body surface area does the vitiligo affected? Less than 1%Less than 10%More than 10%Scalp One sideBoth sideHairs/Head One sideBoth sideEyelids/Eyelashes One sideBoth sideFace One sideBoth sideLips/Mouth One sideBoth sideChest/Breast One sideBoth sideStomach One sideBoth sideBack One sideBoth sideUnderarms One sideBoth sideArms/Elbow One sideBoth sideWrist/Hands/Fingers One sideBoth sideHips One sideBoth sideGenitals One sideBoth sideButtocks One sideBoth sideLegs One sideBoth sideKnees One sideBoth sideFeet One sideBoth 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? EverydayOnce a weekOnce a monthOnce in blue moonDid you ever have blistering sunburn? NoYesNeverIf you answered "yes", that you had a previous sunburn, please explain when this occurred? Less than 2 yearsMore than 2 yearsHave you ever used tooth bleaching products? If so, when? NoYesNot at allDo you now or have you used hair bleaches? NoYesNot at allPlease 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? NoYesNeverDo you have or have you ever had any of these ? AsthmaAllergiesEczemaDo you have or have you ever had intermittent abdominal cramping? NoYesDon’t knowAre you lactose/Gluten intolerant? NoYesDon’t knowDid you ever get allergy shots? NoYesNeverIf yes: Which allergens did you get shots for? Do you have any other autoimmune diseases other than vitiligo? NoYesNeverIf 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.)? NoYesDoes your vitiligo get worse or spread after stressful events occur? NoYesNot at allDo you have friends with vitiligo (circle one)? NoYesHad a loved one passed away within the 2 years prior to developing vitiligo? NoYesWebsiteSubmit