Sierra Rheumatology
Symptom screening

ANA (+) Screening for Systemic Lupus Erythematous

Symptom screen used when a patient has a positive ANA blood test result.

About this form

If your blood test was positive for antinuclear antibodies (ANA), this short screen helps us determine whether further evaluation for lupus or another autoimmune condition is appropriate. Please check every symptom you have currently or have experienced recently.

About 4 minutes
Progress
0%
Patient information
ANA (+) Screening For Systemic Lupus Erythematous

Please check every symptom you have currently or have experienced recently.

Symptoms
Nasal / Genital Ulcers — additional detail

If you checked Nasal / Genital Ulcers above, please specify.

Type
Oral Ulcers — additional detail

If you checked Oral Ulcers above, please specify.

Site
Type
Anything else?
Sign & submit
Patient signature *Sign with your finger, mouse or trackpad in the box below.
Sign here with your finger, mouse or trackpad

Your signature will appear on the exported PDF.

Submitting transmits this form securely to our office. Export to PDF works even with partial answers — useful if you want a printed copy to bring in. For urgent medical issues, please call our office or 911.

Trouble with the form?

Call our office and we'll either walk you through it or send a paper version.

Call (916) 677-4744← All forms