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Find your chances Form
Full Name:
Email:
Priority:
Low
Medium
High
Urgent
Emergency
Critical
Age
*
Sex
*
Male
Female
Race
*
White
Black
Brown
Yellow
Country
*
Detail of affected parts?:
*
When did it start ?:
*
Biggest area (size/ location):
*
Smallest area (size/ location):
Is any of these affected?:
Lips
Finger Tips
Genitalia
What about hair in affected areas?:
*
Hair have pigment
Pigment is reduced/ some hair have pigment
No hair have pigment
No hair in affected area
History of re-pigmentation:
No
Yes, spontaneous
Yes, with treatment
Family history details (specify Grand Parents, Siblings etc):
Who made the diagnosis?:
*
Self
Primary physician
Dermatologiest
Basis of diagnosis:
*
Visual examination
Clinical history
Skin biopsy
Have pregnancies affected your disease?:
No applicable
Improved
Worsened
No change
Family history:
NO
Yes
How has your vitiligo behaved in last six months?:
No change
Progressive
Improving
Spreading in some area's and repigmenting is other
Summary of any co-existing chronic disease?:
Message Details
:
Subject:
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