anemia, lupus, Addison disease, and adult-onset insulin-dependent diabetes. medical conditions that you or any of your relatives have, such as diabetes …
|Please Take Part in an International |
|Study to Find Vitiligo Genes |
|Do you have Vitiligo, or have you had it in the past? Or, does someone in your family|
|have Vitiligo? If so, would you or they be willing to take part in a major research |
|project on Vitiligo? |
|We have put together an international team of scientists to find the genes that cause|
|Vitiligo Thus far, we have found that at least 5 genes contribute to causing |
|Vitiligo in different families; on chromosomes 1, 7, 8, 9, and 17 We dont know |
|what most of these genes are yet, and so we need additional patients and families to |
|narrow our search Our goal is to discover the causes of Vitiligo, and the other |
|autoimmune diseases that are often associated with Vitiligo-thyroid disease, |
|rheumatoid arthritis, psoriasis, pernicious anemia, lupus, Addison disease, and |
|adult-onset insulin-dependent diabetes We are currently focusing both on families |
|in which more than one person has vitiligo or these other diseases and on individual |
|people with vitiligo but no
affected relatives Please give serious consideration to |
|participating Our long-term goal is to better understand the causes of Vitiligo and|
|these related diseases, so as to develop better treatments and even approaches to |
|prevention of these diseases altogether |
|The first step in your participating is to fill out the attached questionnaire and |
|mail or email it to us We will then contact respondents that might be appropriate to|
|the study to get further information and arrange for a saliva spit sample or, |
|occasionally, a small blood sample We thank you in advance for your help, and we |
|look forward to hearing from you |
|Richard A Spritz, MD |
|Professor and Director |
|Human Medical Genetics Program |
|University of Colorado Health Sciences Center |
|PO Box 6511, Mail-stop 8300 |
|Aurora, CO
80045 USA |
USA Vitiligo Family Study Questionnaire
We are carrying out a study to better understand Vitiligo and related
autoimmune diseases and to eventually discover the genes that cause these
disorders We would appreciate your help This form should be filled in by
or for one person in your family that has Vitiligo Please write clearly
If there is not enough room for your answers, please continue on a sheet of
paper and attach it to this form
NOTE: All personal information will be kept in confidence and will not be
used for anything other than this study
IMPORTANT: When we ask about brothers, sisters, parents, etc, we are
referring to blood relatives not relatives by marriage or adoption
Similarly, brothers/sisters means people with the same mother and father,
not half-brothers, etc Half-brothers and half-sisters should be indicated
specifically
1 If you are the person with Vitiligo, please go to question 2 If you
are filling out this form for someone else in which case, from
question 3 onwards, you refers to the person with Vitiligo, please
enter their name here:
2
Please enter your name, address, telephone number and email address
EMAIL address:
3 What is your age? _____, sex? _____, and age when Vitiligo first
appeared? _____
4 How much of your skin would you say is affected by Vitiligo at
present? check one
___ Up to 25 ___ Up to 26-50 ___ 51-75 ___ Up to 76-
100
5 Would you be willing to take part in this project by giving a small
saliva sample? ________
6 For each brother or sister willing to take part in the project,
please provide the following: If they have never had Vitiligo, write N
|Name |Phone Number |Age|Sex|Age When Vitiligo First Appeared |
| | | | | |
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7 Is your mother alive? ______ If so, would she be willing to give a
saliva sample? ______
8 Is your father alive? ______ If so, would he be willing to give a
saliva sample? ______
9 Who else in your family has Vitiligo? Please give their age when it
first appeared, if known [For example: mother 10, son 5,
fathers sister teens]
____________________________________________________________________________
_________________
____________________________________________________________________________
_________________
____________________________________________________________________________
_________________
10 Please briefly describe any special medical conditions that you or
any of your relatives have, such as diabetes specify insulin-requiring
versus non-insulin requiring and approximate age of onset, pernicious
anemia, psoriasis, rheumatoid arthritis, thyroid problems, lupus, Addisons
disease, etc do not include infections, cancer or injuries
|Condition |Who has condition eg, aunt, me, |
|
|etc |
| | |
| | |
| | |
| | |
| | |
| | |
11 How many brothers do you have? _____ How many sisters? _____
12 How many brothers does your mother have? _____ How many sisters?
_____
13 How many brothers does your father have? _____ How many sisters? _____
14 How many children do you have? _____
15 If your child has Vitiligo, is their other parent willing to take part
in this study? _____
16 Has that parent ever had Vitiligo? _____ Has anyone else in that
parents family ever had Vitiligo? _____
17 Please check whichever of the following ethnic groups fits you best:
|___ White/Caucasian |___ |___ Hispanic |
| |African-American/African| |
|___ Native
American |___ Indian/Pakistani |___ Middle-Eastern |
|___ Asian |___ Mixed Race |___ Other |
18 If you answered mixed race or other, please explain:
19 What is your eye color and natural hair color?
Eye Color: Hair Color:
If there is any other information you think may be useful to us,
particularly your vitiligo treatment history and response to treatment,
please add it here or on another page:
Thank you very much for your help
Once you have completed the form, please return it to:
Richard A Spritz, MD
Professor and Director
Human Medical Genetics Program
University of Colorado Health Sciences Center
PO Box 6511, Mail-stop 8300
Aurora, CO 80045 USA
Email: RichardSpritz@ucdenveredu
Source:dhcs.ca.gov
