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Vitiligo Quality of Life Study
1.
During the past month:
0 - Not at all
1
2
3
4
5
6- All of the time
1. Have you been bothered by the appearance of your skin condition?
0 - Not at all
1
2
3
4
5
6- All of the time
2. Have you felt frustrated about your skin condition?
0 - Not at all
1
2
3
4
5
6- All of the time
3. Has your skin condition made it hard to show affection?
0 - Not at all
1
2
3
4
5
6- All of the time
4. Has your skin condition affected your daily activities?
0 - Not at all
1
2
3
4
5
6- All of the time
5. When you were talking to someone, have you worried about what they may be thinking of you?
0 - Not at all
1
2
3
4
5
6- All of the time
6. Have you been afraid that people will find fault with you?
0 - Not at all
1
2
3
4
5
6- All of the time
7. Have you felt embarrassed or self-conscious because of your skin?
0 - Not at all
1
2
3
4
5
6- All of the time
8. Has your skin condition influenced the clothes you wear?
0 - Not at all
1
2
3
4
5
6- All of the time
9. Has your skin condition affected your social or leisure activities?
0 - Not at all
1
2
3
4
5
6- All of the time
10. Has your skin condition affected your emotional well-being?
0 - Not at all
1
2
3
4
5
6- All of the time
11. Has your skin condition affected your overall physical health?
0 - Not at all
1
2
3
4
5
6- All of the time
12. Has your skin condition affected your grooming practices (i.e. hairstyle, use of cosmetics)?
0 - Not at all
1
2
3
4
5
6- All of the time
13. Has your skin condition affected your sun protection efforts during recreation (i.e. limiting exposure time during peak sun hours, seeking shade, wearing hat, long sleeves or pants)?
0 - Not at all
1
2
3
4
5
6- All of the time
14. Has your skin condition affected your chances for making new friends?
0 - Not at all
1
2
3
4
5
6- All of the time
15. Have you been worried about progression or spread of disease to new areas of the body?
0 - Not at all
1
2
3
4
5
6- All of the time
2.
Please check how severe you currently feel your skin condition is:
0 - No skin involvement
1
2
3
4
5
6 - Most severe case
16. Severity of skin condition
0 - No skin involvement
1
2
3
4
5
6 - Most severe case
3.
How old are you?
18-24 years
25-34 years
35-44 years
45-54 years
55-64 years
65-74 years
75 years or older
4.
Do you identify as male, female, or other? If other, please list.
Male
Female
Other
5.
What is your ethnicity? (Check all that apply)
American Indian/Native American
Asian
Black/African American
Hispanic/Latino
White/Caucasian
Pacific Islander
Other (please specify)
6.
How long ago were you diagnosed with vitiligo?
Less than 1 year ago
1 - 5 years ago
5 - 10 years ago
10 - 20 years ago
More than 20 years ago
7.
On what part of your body is your vitiligo most severe?
Arms/Legs
Chest/Stomach/Back
Hands/Feet
Face
8.
What is the highest degree or level of schooling that you have completed? If currently enrolled, highest degree received.
No schooling completed
Nursery school to 8th grade
Some high school, but no diploma
High school graduate, diploma, or the equivalent (example: GED)
Some college credit, but no diploma
Associate degree
Bachelor's degree
Master's degree
Doctorate degree (MD, PhD, etc)
Trade/Technical/Vocational Training
9.
Are you employed? If yes, please state your occupation.
No
Yes
10.
What treaments are you currently receiving for your vitiligo?
Phototherapy
Topical therapy (Topical steroids or other topicals)
No treatment
Other (please specify)