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  2. 2014
  3. September
  4. H
  5. hyperpigmentation questionnaire
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how old are you?
18-24
25-34
35-44
45-54
over 60
 
 
 
Gender
 
male
 
female
 
 
 
What is your marital status:
 
married
 
single
 
separated
 
divorced
 
widowed
 
 
 
What is your country of origen?
   
 
 
 
what language do you speak?
   
 
 
 
What do you consider your ethnicity?
   
 
 
 
Are you working?
 
yes
 
no
 
retired
 
 
 
what is the highest level of education completed?
 
no school
 
some high school
 
High School
 
Some collage
 
Bachelor's Degree
 
Master's Degree
 
Doctorate
 
 
 
How often do you conduct surveys?
 
yes
 
no
 
yes but several years ago
 
 
 
what was your diagnosis?
 
sun spots
 
melasma
 
acanthosis nigricans
 
Post-inflamatory hyperpigmentation
 
None of the above
 
name your diagnosis:
 
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