Rheumatoid arthritis

SisSLE Questionnaire: SLE Proband Data

This questionnaire is designed to provide a brief demographic background. Al the
information you provide wil be kept confidential. Your participation is greatly
appreciated.
Name:
Home Phone: ___________________ Cel Phone: _______________ Email: __________________ Date of Birth: ____________________ State/Country of Birth:
Preferred mailing address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional contact person’s name ______________________________________________
Phone number (e.g. parents) ____________________________________cell #? Yes No

Have you participated in any other research study at the FIMR? No Yes (name) ___________

Have you spoken with your sister (s) and has she agreed to be contacted to
learn more about the study?

Sister’s Names
____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ___________________________________________
Family Tree
Your Ethnic Background (based on where your 4 grandparents came from –
check all that apply)

Northern European (England, Scotland, Wales, Ireland, N. France, Hol and, Belgium, Scandinavian (Denmark, Norway, Sweden, Finland) Southern European (Spain, Portugal, Italy, S. France) Central European (Germany, Austria, Hungary) Eastern European (Russia, Poland, Romania, Ukraine, Lithuania, Latvia, Estonia, Czech East Mediterranean (Greece, Turkey, Croatia, Bosnia, Yugoslavia, Albania) Middle East French Canada South Africa Ashkenazi Jewish Sephardic Jewish Unknown South America (includes Central America) Latino/Hispanic West Indian Native Hawai an/Pacific Islander SLE History:

How old were you when you first developed symptoms of SLE? ______Month/Year______
How old were you when diagnosed with SLE? _______

What were your first symptoms before diagnosis? ____________________________________
Diagnosing Dr.’s Name:___________________________________Speciality:
Address: _______________________________________________________________ Town/City: ___________________________ State: ____________Zip: ____________ Phone number: __________________________Fax number: ______________________ Office Contact: ______________________________ Email: _______________________ Current Dr.’s Name:_____________________________________ Speciality:
Address: _______________________________________________________________ Town/City: ___________________________ State: ____________Zip: ____________ Phone number: __________________________Fax number: ______________________ Office Contact: ________________________ Email: ________________________________
Medication History:
Please check if you have ever taken any of the fol owing medications for SLE
NSAID (anti-inflammatories -i.e. Aspirin, Ibuprofen, Naprosyn, Celebrex, Voltaren, Feldene, Vioxx) Prednisone (or other steroids by mouth) Other ________________________________________________________ Have you ever had…
Yes
No
?
Photosensitivity such as a raised skin rash from sun exposure (not sunburn) Sores in your mouth or nose for more than two weeks at a time Swelling AND pain in your joints for more than 3 months Has it ever been painful to take a deep breath for more than a few days Have you ever been told you have protein in your urine Have you ever been told you have white blood cells in your urine Have you ever had neurological symptoms such as a seizure or convulsion Have you ever been psychotic, had hal ucinations or been so seriously mental y il that hospital admission was required? Have you ever had blood tests that showed any of the following:
Yes
No
?
A very low white blood cell count not due to medications Very low platelet count not due to medications An immunologic disorder such as Anti DNA antibodies on blood test APLA (Anti-phospholipid antibodies) A false positive blood test for syphilis A positive ANA (antinuclear antibody) How did you find out about the SisSLE Research Study? _________________________ Allergies: ______________________________________________________________

Source: http://www.sissle.org/documents/affected_sis_questionnaire.pdf