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2014
July
T
Test1
Test1
0%
Exit Survey
Subject ID
:
Initials
:
What is the subject's GENDER
Female
Male
What is the subject's Ethnicity?
Asian
Black
Caucasian
Hispanic
Native American or Pacific Islander
Other or Unknown
What is the subject's date of birth?
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01
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Jan
Feb
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Apr
May
Jun
Jul
Aug
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Oct
Nov
Dec
--
2024
Does the subject have any of the following pre-existing conditions?
None
Asthma
Autoimmune thyroid disease
Autoimmune hepatitis
C1INH deficiency
Inflammatory bowel disease
Defined coagulopathy
Lymphoproliferative disorder
Malignancy
Other
Date of SLE Diagnosis?
--
01
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2024
Duration of SLE-attributable symptoms prior to diagnosis
<4 weeks
4-6 weeks
6-12 weeks
>12 weeks
Describe the onset of the initial episode relative to SLE diagnosis
>6 weeks prior
At time of diagnosis
>6 weeks following
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