Vitiligolanka Online Inquiry
General:
Full Name *
E Mail *
Phone
Address
Priority
Assessment:
Age
Sex
Race
Country
Type of disease
When did it start?
Detail of affected parts? *
Biggest area (size/ location) *
Smallest area (size/ location)
Is any of these affected?
What about hair in affected areas?
History of re-pigmentation:
Family history details (specify Grand Parents, Siblings etc):
Who made the diagnosis?
Basis of diagnosis
Have pregnancies affected your disease?
How has your vitiligo behaved in last six months?
Summary of any co-existing chronic disease?
Do you have family members with Vitiligo?
Do you or family members have any autoimmune diseases?
Do you have a rash, sun burn or other skin problem before?
Do you have some type of stress or physical illness?
Did your hair turn grey before age 35?
Are you sensitive to the sun?
Upload photo of affected area (Optional)
Upload photo 2 of affected area (Optional)
Message details *
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