Signs & Symptoms of Lupus For each symptom listed, write “yes” next to the ones you have experienced in the past, or are currently experiencing. If you are unsure, write “don’t know”. 1. Achy, painful and/or swollen joints for more than three months: _______ 2. Fingers and/or toes become red or blue, or feel numb or painful: _______ 3. Sores in your mouth or nose that lasted more than ve days, or sores on your skin that would not heal: _______ 4. Anemia, a low white blood cell count, or a low platelet count: _______ 5. Redness or rash in the shape of a butter y across your nose and cheeks: _______ 6. A fever over 100 degrees for more than a few days: _______ 7. Photosensitivity, a reaction to sun or light that causes a skin rash to appear or get worse: _______ 8. Chest pain while taking deep breaths: _______ 9. Protein in your urine, or swelling in your legs and ankles on both sides at the same time: _______ 10. Persistent, extreme fatigue and weakness for days or weeks at a time; even after plenty of sleep: _______ 11. Seizures or unexplained confusion that lasts more than an hour: _______ 12. Blood clot(s): _______ 13. Heart Attack or Stroke: _______ 14. Miscarriage(s): _______ 15. Sudden, unexplained hair loss: _______ Risk Factors for Lupus Gender, ethnicity, age, and family medical history may all contribute to your risk for Lupus. Nine out of 10 people who develop Lupus are women, and most women develop Lupus between the ages of 15 and 44. Hispanic, Asian, Native American and African-American women are also two to three times more likely to develop Lupus than Caucasian women. 1. Age: _____ It is important for you to know the warning signs and symptoms of Lupus. Complete this simple checklist to help you recognize the symptoms and risk factors for Lupus. Answer each question in terms of your current and past health status. If you have had symptoms like these, especially if you have had several, talk to your doctor about Lupus. e checklist is only meant to help you recognize the signs and symptoms of Lupus, and as a guide for you and your doctor to discuss your possible risk for developing Lupus.
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: _________________________________ _________________________________
2. Ethnicity: ____________________ 3. Gender: Male____Female____
Phone Number: __________________
Email Address: ____________________________
4. Does your family have a history of autoimmune disorders such as rheumatoid arthritis, Sjogren’s syndrome, type 1 diabetes, Raynaud’s Phenomenon, Scleroderma, mixed connective tissue disease, multiple sclerosis (MS), or “over-“ or “under-“ active thyroid?
Emergency Contact Name: __________________________________
THE NUMBER OF AMERICANS LIVING WITH LUPUS, AS ESTIMATED BY THE LUPUS FOUNDATION OF AMERICA
For more information, please visit www.lupus.org
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