Questionnaire about Lupus

Questionnaire about Lupus

Please answer a few questions so that we can better understand your situation.**

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Your name:		Patient Name (if different)
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Sex: Female Male	Age:
Race:	Weight: (pounds)
How many years ago when your lupus was diagnosed? No Answer Less than 1 year 1 to 5 years 6 to 10 years 10 to 20 years over 20 years	What type of lupus do you have? DLE SLE Drug Introduced Lupus Neonatal Lupus
Do you know any family member who is diagnosed of lupus? No Answer Yes No	What symptoms of lupus do you have? Skin Rashes Fever Joint Pain Fatigue Sensitivity to the Sun Muscle Pain Kidney Problems
How serious is your lupus? No Answer Mild Moderate Severe	What type of treatment have you used before? Topical. what kind? Oral Medication. what kind?
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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.