Sandra Pereda

Lupus Symptoms Checklist

Communicating your symptoms to your care provider is an important part of identifying
a medical issue. Remember to take this checklist with you to your next appointment.

Symptoms I have had this When did you first How often do How long does this
symptom since experience this you have this symptom typically
my last doctor visit symptom? symptom? last?
___ hr/days/weeks

Skin

Rash across cheeks and nose

Skin rash of raised red patches Yes 10+ Years ago A few times a year 5 Days

Rash on skin exposed to sunlight

Mouth or nose ulcers (usually painless)

Hair Loss

Pain and Swelling

Swollen, stiff or painful joints – at least two No 1 - 2 Months ago A few times a week 8 Days

Fingers or toes that turn white, blue, or purple

often with numbness

Pain in the chest with deep breath, laugh or cough

Sharp chest pain behind the breastbone or in the

left side of the chest

Pain and tenderness in the abdomen

Aching muscles

Swelling of legs and/or feet No A few days ago Once a year 8 Hours

Fever

Recurrent low grade fevers under 101˚ F

Neurological/Cognitive
Brain fog – lack of concentration, memory loss,
Yes 3 - 5 Years ago Every few months 8 Hours
headaches

Seizures

Page 1 of 2 | © 2021 Exagen Inc. All Rights Reserved. W1013 (06/21) (continued on next page)
Sandra Pereda

Lupus Symptoms Checklist (continued)

I have had this When did you first How often do How long does this
Symptoms symptom since experience this you have this symptom typically
my last doctor visit symptom? symptom? last?
___ hr/days/weeks

Fatigue and Sleep

Fatigue

General

Dry eyes or dry mouth

Bruising easily Yes 5 - 10 Years ago Once a week 2 Days

Weight change

Anemia – low red blood cell count

Urine that is an abnormal color or frothy Yes 3 - 5 Years ago Every few months 8 Hours

Additional Information

Does anything make your symptoms better No

or worse?

Come and Go
Are your symptoms constant or do they
come and go?

No
Do your symptoms get worse at a certain time
of the day?

No
Has any member of your family had lupus or another
autoimmune disease?

No
Have you had a positive anti-nuclear antibody
(ANA) test?

Notes you would like your provider to know:

This symptom checklist was developed by Exagen Inc., a CAP-accredited and CLIA certified rheumatology specialty laboratory.
Exagen Inc. is the maker of the AVISE testing portfolio. Powered by proprietary CB-CAPs, AVISE delivers the most advanced
autoimmune test available for lupus and other CTD patients and their providers.

Page 2 of 2 | © 2021 Exagen Inc. All Rights Reserved. W1013 (06/21)