| When did it appear first ? |
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| What are the affected parts? |
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| What is the size and location of biggest area? |
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| What is the size and of smallest area? |
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| Is any of the following areas affected? |
Finger Tips
Lips
Genitalia |
| How are the hair in the affected areas? |
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| Has any affected area ever spontaneously re-pigmented? If yes, please give details |
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| What has been the overall course of disease? |
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| How have your pregnancies affected your disease? |
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| Summary of any co-existing chronic disease? |
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| How has your vitiligo behaved in last six months? |
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| Summary of medication over past sex months? |
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Is there any history of vitiligo in your family?
(If yes, please specify Grand Parents, Parents Children Siblings Parents, and Siblings) |
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