Zip Code: Male Female Lupus Patient yes no Number and ages of children Ethnic Background (self); African American Asian Caucasian Latino Other Use the following scale to answer question 1 1 = not at all 2 = once in a while 3 = sometimes 4 = a lot 5 = all the time 1. I can talk to my family members about: a. My fears about lupus 1 2 3 4 5 b. My feelings in general 1 2 3 4 5 c. My problems in general 1 2 3 4 5 d. My aches and pains 1 2 3 4 5 e. What's different in my life since I got sick 1 2 3 4 5 f. Helping me find solutions to problems when I get sick 1 2 3 4 5 Comments: 2. When I feel sick or down or tired, I (check all that apply) Rest Talk to my family Talk to friends Do something quiet like read or watch TV Cry, get mad, or otherwise show my feelings Push myself to work or play harder Get away from everybody Try to do or think of something funny Get upset and feel sorry for myself Other Comments: Use the following scale to answer question 3. 1 = not at all 2 = a little confident 3 = fairly confident 4 = usually confident 5 = very confident 3. How confident are you in your knowledge of: a. Lupus symptoms 1 2 3 4 5 b. Lupus treatments 1 2 3 4 5 c. Lupus laboratory tests 1 2 3 4 5 d. How Lupus affects families 1 2 3 4 5 e. Legal or employment issues 1 2 3 4 5 f. Insurance issues related to Lupus 1 2 3 4 5 g. Psychological or emotional issues related to Lupus 1 2 3 4 5 Comments: 4. I have gotten information about Lupus from (check all that apply) The Lupus Foundation of Pennsylvania Other health organizations (please specify below) Health insurance plan Physician's office Internet Support groups Books and literature Comments:
