SLE Clinical Evaluation Form
Please complete this form to assist with the clinical evaluation of SLE. Do not enter sensitive personal or financial identifiers.
Evaluation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Reference Code (no names or IDs)
Primary Symptoms Present
*
Fatigue
Joint pain
Skin rash
Fever
Photosensitivity
Other
General Health Status
*
Excellent
Good
Fair
Poor
Pain Severity (0 = None, 10 = Worst)
None
0
1
2
3
4
5
6
7
8
9
Worst
10
0 is None, 10 is Worst
Current Medications (if any, do not include sensitive info)
Physical Findings
Laboratory Findings (if applicable)
Clinician's Observations / Notes
Follow-up Recommended
Yes
No
Submit Evaluation
Should be Empty: