Protocol - Personal and Family History of Autoimmune and Inflammatory Disorders

Condition

P

Y

N

Prominent rash on cheeks for more than 1 month

Skin breaks out in the sun (not sunburn)

Sores in mouth for more than 2 weeks

Arthritis or rheumatism for more than 3 months

Pain for more than a few days when taking deep breath (pleurisy)

Protein in urine

Low blood counts (anemia, low white blood cell count, or low platelet count)

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Idiopathic thrombocytopenia purpura (ITP)

Bruise easily

Positive skin test for tuberculosis (tuberculin, PPD, or TINE test)

Positive blood test for syphilis (VDRL or RPR)

Seizure, convulsion, or fit

Mental illness (requiring hospital admission) or psychosis or hallucinations

Rapid hair loss NOT due to chemotherapy

Mononucleosis (mono)

If yes or still present, age you first had mono

0-12[ ][ ] 13-19 [ ] 20+

Condition

P

Y

N

Chronic fatigue

Psoriasis

Scleroderma

Vitiligo

Fever blisters on lips

Poison ivy

Athletes foot

Fibromyalgia

Arthritis

Osteoarthritis

Bunions

Myasthenia gravis

Slow heart beat (less than 50 beats per minute)

Recurrent chest pain

Heart attack

Asthma

Recurrent heart burn

Ulcer (stomach or duodenal)

Recurrent diarrhea

Hemorrhoids (piles)

Jaundice

Appendicitis

Cancer

Kidney stones

Recurrent urinary tract infections

Condition

P

Y

N

Recurrent vaginitis

Depression

Chronic headaches

Anxiety or panic disorder

Carpal tunnel syndrome

Anemia

Pernicious anemia

Diabetes

Thyroid problems

Infertility

Multiple miscarriages

High blood pressure

Phlebitis

Pulmonary embolus

Stroke

Blood clot

Sjögrens syndrome

Dry eyes

Dry mouth

False teeth

Seasonal allergies (or hay fever)

Sinus problems

Graying of all or nearly all hair before 35

Baldness

Varicose veins

Breast implants

Spleen removed

Diseases

1

Systemic lupus erythematosus (SLE)

2

Rheumatoid arthritis

3

Sjögrens syndrome

4

Discoid lupus

5

Autoimmune thyroid disease (AITD)

6

Type 1 diabetes (Juvenile onset)

7

Type 2 diabetes (Adult onset)

8

Myasthenia gravis

9

Scleroderma

10

Addisons disease

11

Idiopathic thrombocytopenia (ITP)

12

Antiphospholipid syndrome

13

Graying of all hair before age 35

14

Other autoimmune disorder

Relationships

1

Self

2

Full sibling

3

Half sibling

4

Child

5

Grandchild

Mothers Side

Fathers Side

6

Mother

7

Mother

8

Aunt

9

Aunt

10

Uncle

11

Uncle

12

Cousin

13

Cousin

14

Grandmother

15

Grandmother

16

Grandfather

17

Grandfather

18

Other

19

Other

Disease

Relationship

Name of Relative (if not self)

2

1

7

15

JANE DOE

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