Section E - SLAQ
|SLAQ |
|SLE Activity Questionnaire – self-administered |
1. In the past 3 months, have you had a lupus flare (A lupus flare is when your lupus gets worse)?
|No, no flare |Yes, mild flare |Yes, moderate flare |Yes, severe flare |
Which of the following responses best describes you? (Please mark the circle.)
|2. Please review the following list of lupus symptoms. IN THE PAST 3 MONTHS, how bad has|No Problem |Mild |Moderate |Severe |
|each of the symptoms been? Please (√) a column for each symptom. | | | | |
|Lost weight without trying | | | | |
|Fatigue | | | | |
|Fevers (>101 (F, 38.5 (C) taken by thermometer | | | | |
|Sores in mouth or nose | | | | |
|Rash on cheeks (shaped like a butterfly) | | | | |
|Other rash (Where?_______________________) | | | | |
|Dark blue or purple spots you could feel on your skin | | | | |
|Rash or feeling sick after going out in the sun | | | | |
|Bald patches on scalp or clumps of hair on pillow | | | | |
|Swollen glands (nodes) in neck | | | | |
|Shortness of breath | | | | |
|Chest pain with a deep breath | | | | |
|Fingers or toes turning dead white or very pale in the cold (Raynaud’s) | | | | |
|Stomach or belly pain | | | | |
|Persistent numbness or tingling in you arms or legs | | | | |
|Seizures | | | | |
|Stroke | | | | |
|Forgetfulness | | | | |
|Feeling depressed | | | | |
|Unusual headaches | | | | |
|Muscle pain | | | | |
|Muscle weakness | | | | |
|Pain or stiffness in joints | | | | |
|Swelling in joints | | | | |
3. Please rate the disease activity of your lupus DURING THE PAST 3 MONTHS on the scale below, where 0 is no activity and 10 is the most activity. (Fill in the circle for you most active day.)
No activity |0 |1 |2 |3 |4 |5 |6 |7 |8 |9 |10 |Most activity | |
4. How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST 3 MONTHS?
(Fill in the circle for you most fatigued day.)
Fatigue is a
major problem |0 |1 |2 |3 |4 |5 |6 |7 |8 |9 |10 |Fatigue is
no problem | |
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