* 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?
2. Have you felt frustrated about your skin condition?
3. Has your skin condition made it hard to show affection?
4. Has your skin condition affected your daily activities?
5. When you were talking to someone, have you worried about what they may be thinking of you?
6. Have you been afraid that people will find fault with you?
7. Have you felt embarrassed or self-conscious because of your skin?
8. Has your skin condition influenced the clothes you wear?
9. Has your skin condition affected your social or leisure activities?
10. Has your skin condition affected your emotional well-being?
11. Has your skin condition affected your overall physical health?
12. Has your skin condition affected your grooming practices (i.e. hairstyle, use of cosmetics)?
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)?
14. Has your skin condition affected your chances for making new friends?
15. Have you been worried about progression or spread of disease to new areas of the body?

* 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

* 3. How old are you?

* 4. Do you identify as male, female, or other? If other, please list.

* 5. What is your ethnicity? (Check all that apply)

* 6. How long ago were you diagnosed with vitiligo?

* 7. On what part of your body is your vitiligo most severe?

* 8. What is the highest degree or level of schooling that you have completed?  If currently enrolled, highest degree received.

* 9. Are you employed? If yes, please state your occupation.

* 10. What treaments are you currently receiving for your vitiligo?

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