This questionaire can be copied to your text program, than filled with your information and sent to Dr. Matschurat´s e-mail address: firstname.lastname@example.org
Dr. Thomas Matschurat, Steinkirchnerstraße 8, D 82166 Gräfelfing,
Tel:.++49 (0) 89 8982650, Fax. ++49 (0) 89 89826598
Your Name and First Name: Your Date of Birth:
1. In which year did the first signs of VITILIGO arise? Year:__________________
2. Which skin portions were affected first?
3. Which skin areas followed? (Sequence, if you still know it)
4. Which areas are affected today? Please also indicate the size of your white areas:
6. Which therapies did you try so far?
Was this treatment successful? Yes: No: (X)!
Please Describe the success of this treatment:
Questionnaire Vitiligo (page 2) Your name again please:
8. Do you experience any of the following conditions:
Thyroid subfunction (Hypotyreosis)?
Other thyroid ill conditions?
Low blood pressure?
Higjh blood pressure?
9. Which assumption do you have personally concerning a possible cause for the occurrence of your Vitiligo?
10. Do you believe that your vitiligo worsens under stress conditions?
I am informed about the following consultation fees which come into effect in case I take advantage of Dr. Thomas Matschurat´s personal medical advice for treatment of my vitiligo condition:
-First consultation to start your treatment (about 1 hour). Fees incl. written treatment plan plus prescriptions for 6 months: 135 EUR
.-Second consultation after 6 months (about 30 minutes). about 60 EUR.
-Consecutive consultations after this, as needed. Corresponding fees: about 20 EUR for each started 15 minutes of consultation
about 10 EUR for each consecutive prescription (pus postage for patients outside Europe).- My name again:
(instead of a signature, which is not necesary if you send this questionaire and aknowlidgment of fees by e-mail)