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Directions: |
| Copy Questionnaire |
| Click Here, |
| then Paste, Answer Questions and send |
Questionnaire Name: Tel: State: Email Address: 1) What is Lupus? 2) What are three symptoms that has effected you in last year?
3) How does these symptoms effect you?
4) How many times have you tried to get a diagnosis? 5) Does anyone in your family have lupus or arthritis? 6) Have you experienced hair loss?. 7) Is your skin sensitive to the sunlight? 8) Do you break out in rashes? 9) Has your energy levels drastically decreased? 10) Has your blood test revealed that you had a high A1A? 11) Do you get sores in your mouth that last a week or more? 12) Do you get persistently fatigue. 13) Do you get chest pains while taking a deep breath? 14) Seizures? 15) Unexplained hair loss 16) Fingers or toes turn red or blue 17) Medicine sensitivity?
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