Lupus Diagnostic Criteria Checklist Form
Complete this Lupus Diagnostic Criteria Checklist Form to assess the presence of key clinical and laboratory findings commonly used in lupus screening.
Malar (butterfly) rash present
*
Yes
No
Unknown
Discoid rash present
*
Yes
No
Unknown
Photosensitivity
*
Yes
No
Unknown
Oral ulcers (painless)
*
Yes
No
Unknown
Non-erosive arthritis (joint pain/swelling)
*
Yes
No
Unknown
Serositis (pleuritis or pericarditis)
*
Yes
No
Unknown
Renal disorder (proteinuria or cellular casts)
*
Yes
No
Unknown
Neurologic disorder (seizures or psychosis)
*
Yes
No
Unknown
Hematologic disorder (anemia, leukopenia, lymphopenia, thrombocytopenia)
*
Yes
No
Unknown
Immunologic disorder and/or positive antinuclear antibody (ANA)
*
Positive anti-dsDNA
Positive anti-Sm
Positive antiphospholipid antibodies
Positive ANA
None of the above
Submit
Should be Empty: