Vitiligo Assessment

Age*

Gender*

Male

Female

Skin Tone*

Fair

Olive

Dark

How long have you had Vitiligo?*

Does anyone else in your immediate family have Vitiligo?*

Where on your body did the first white spots or patches appear?

On what parts of your body do you now have Vitiligo?

What percentage of your body now has the Vitiligo Condition?*

5% or less

5% - 10%

10% - 20%

20% - 30%

30% - 50%

50% or more

Have you ever been pregnant?

N/A

Yes

If 'Yes', did Vitiligo first appear after giving birth?

N/A

Yes

Did you suffer any 'Mental or Physical Trauma' before the Vitiligo condition started?

Yes

Do you spend a lot of time in the sun, reside close to the sea or live in a humid climate?

Yes

Do you suffer from Allergies or Scratching?

Yes

Is your Thyroid functioning correctly?

Yes

Uncertain

Do you consider your current diet to be nutritional?

Yes

Uncertain

Please write a brief description of any previous medications or treatments you have tried in the past and what the results were:

If you would like to add anything else to this form that you feel may be relevant to your Vitiligo condition, please add it below:

Optional Vitiligo pic upload of a spot or patch that you feel may help us with your assessment:

Country*

Name*

Email*

Would you like to receive our Montly Newsletter?*

Yes

Please complete the form above and submit it. We shall analyse your history, and email you back with our recommendations and/or request more information.

Rest assured that we do not distribute or share any of your information. All information received from this form shall be kept private and not disclosed to any other party.

This is a free service and each form shall be assessed individually by one of our professional consultants.

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