Lupus Clinical Evaluation Form
Complete this form to document the clinical evaluation of a patient with lupus. Please fill in all relevant clinical findings and observations.
Patient Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Lupus Symptoms Present
*
Fatigue
Joint pain/swelling
Rash
Fever
Mouth ulcers
Photosensitivity
Hair loss
Other
Symptom Severity (1 = Mild, 5 = Severe)
*
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Duration of Current Symptoms (in weeks)
*
Physical Examination Findings
*
Relevant Laboratory or Imaging Findings
*
Current Medications
*
Physician Comments / Assessment
Follow-up Plan / Next Steps
Submit Evaluation
Should be Empty: