Questionnaire about Vitiligo


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

Your name:

 

Patient Name (if different)

  

Your Email Address:

  

Verify Email Address:

Sex:

Female Male

Age:

Race:

Weight:

(pounds)

How many years have you had Vitiligo?

Less than 1 year      1 to 5 years     6 to 10 years     11 to 20 years     over 20 years

Which part of your body does the Vitiligo affect?

Face  Neck  Arm  Leg  Hand  Foot  Body

How Serious do you think your Vitiligo is?

Mild  Moderate  Severe

Do you have any family member who has Vitiligo?

Yes  No 

Do your white spots keep spreading?

Yes  No 

Have you tried any alternative treatment?

Yes,  what kind?
No

How did you hear about us?


Please Specify: (such as Google, WebMD, etc..)

Please add any comments and questions you have below:

Attachment1:

Attachment2:

Attachment3:

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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.