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General Information

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Priority	Low Medium High Urgent Emergency Critical

Assessment request

Age:*
Sex:*	Female Male
Race:*	White Black Brown Yellow
Country:*
When did it start ?:*
Detail of affected parts?:*
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?:	Not 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 in other
Summary of any co-existing chronic disease?:

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