Questionnaire about Vitiligo

Questionnaire about Vitiligo

Please answer a few questions so that we can better understand your situation.**

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Your name:		Patient Name (if different)
Your Email Address:
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Sex: Female Male	Age:
Race:	Weight: (pounds)
How many years ago when your vitiligo was diagnosed? Less than 1 year 1 to 5 years 6 to 10 years 10 to 20 years over 20 years	Which part of your body does the vitiligo affect? Face Neck Arm Leg Hand Foot Body
Do you know any family member who is diagnosed of vitiligo? Yes No	How serious is your vitiligo? Mild Moderate Severe
Do your white spots keep spreading? Yes No	Have you tried any alternative treatment? Yes if Yes, what kind? No
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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.