Lupus Symptom Checklist Form
Please review the following symptoms and complete the checklist to help track your current health status. This form is designed for self-assessment and does not collect sensitive personal information.
Full Name
First Name
Last Name
Date Completed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate if you are currently experiencing any of the following symptoms.
*
Rows
Yes
No
Not Sure
Fatigue or unusual tiredness
1
2
3
Joint pain or swelling
4
5
6
Skin rashes (including butterfly rash on face)
7
8
9
Sensitivity to sunlight
10
11
12
Mouth or nose sores
13
14
15
Hair loss
16
17
18
Fingers/toes turning white or blue in cold
19
20
21
Chest pain or shortness of breath
22
23
24
Persistent fever
25
26
27
Additional comments or symptoms (optional)
Submit Checklist
Should be Empty: