Lupus Survey Do you have symptoms of Lupus? Please take a moment to complete and return the following survey.
YES
NO
1. Have you ever had arthritis or rheumatism for more than three months? 2. Do your ngers become pale, numb or uncomfortable in the cold? 3. Have you had sores in your mouth for more than two weeks? 4. Have you been told that you have low blood counts-anemia, low white cell count or low platelet count? 5. Have you ever had a prominent rash on your cheeks for more than a month? 6. Does your skin break out after you have been in the sun (not sunburn)? 7. Has it ever been painful to take a deep breath for more than a few days? 8. Have you been told that you have protein in your urine?
______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
9. Have you ever experienced rapid loss of hair? 10. Have you ever had a seizure, convulsion or t? 11. Have you ever been diagnosed as having Lupus or a related disease? 12. Do you know someone who has these symptoms?
Please Note: It is important not to diagnose yourself
If you have answered, “YES” to three or more questions, please complete the following:
Ethnic Group : Caucasion ___ Hispanic ___ Black ___ Asian ___ Other ___
Sex : Male ___ Female ___
Age: _____
Date of Birth: ____/____/____
Name: __________________________________
Address: _________________________________ _________________________________
Phone Number: __________________
Email Address: ____________________________
Emergency Contact Name: __________________________________
24
Made with FlippingBook - Online Brochure Maker