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State Alabama Arizona California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington Wisconson Exp. Date  

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Requested Illustration:

1. PLEASE LIST THE DATE OF THE FIRST DIAGNOSIS:

2. PLEASE NOTE THE TYPE OF LUPUS DIAGNOSED:
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) 

DISCOID LUPUS

DRUG INDUCED LUPUS

3. IS THE CLIENT ON ANY MEDICATIONS FOR THE IMPAIRMENT?
Yes No IF YES, PLEASE DETAIL TYPE AND DOSAGE:

4. IS THE LUPUS ON REMISSION? Yes No
PLEASE LIST DATE OF LAST EXACERBATION

5. HAS THE CLIENT EVER HAD THE FOLLOWING: (PLEASE CHECK ALL THAT APPLY)
LOW BLOOD COUNTS
LUNG INVOLVEMENT (PLEURITIS)
PROTEINURIA
HIGH BLOOD PRESSURE
NEUROLOGIC DISORDER
HEART INVOLVEMENT (PERICATDITIS)
RENAL INSUFFICIENCY OR FAILURE

6. CLIENT'S OCCUPATION FULL TIME PART TIME

7. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
Yes No IF YES, PLEASE DETAIL

8. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
Yes No IF YES, PLEASE DETAIL

9. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: