ANA Screening Form | Sierra Rheumatology

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Sierra Rheumatology Inc.

2207 Plaza Drive, Suite 100, Rocklin, CA 95765

Telephone: (916) 677-4744 Fax: (916) 781-2029

www.sierrarheumatology.com

ANA (+) Screening for Systemic Lupus Erythematous

Ana Screening

Hair Loss /Non - Scarring Alopecia - diffuse thinning or hair fragility, in the absence of other causes such as alopecia areata, drugs, iron deficiency, and androgenic alopecia

Malar Rash - butterfly rash, specifically covering cheeks and the bridge of your nose

Photosensitive Rash - sun exposed surfaces more prone to tender rashes lasting more than 2-3 days

Nasal/ Genital Ulcers - lasting more than a few days

Painful

Painless

Oral Ulcers

Site: Palate - soft /hard | Tongue | Inner cheek

Painful

Painless

Raynaud's Phenomenon - numbness / cold sensation of either digits & toes, sometimes causing pain and discoloration - white, purple, blue, red. Exacerbated by cold temperatures

Arthritis - swelling and/or tenderness in 2 or more joints and at least 30 minutes of morning stiffness for more than 6 weeks

Pleurisy / Pleural Effusion- fluid in the lungs

Pericardial effusion - fluid in the heart

Thrombocytopenia - low platelet count causing abnormal bleeding

Hemolytic Anemia red blood cells are destroyed faster than they can be made, requiring blood transfusions

Leukopenia - decreased number of white blood cells

Kidney involvement and/or disease

Seizures

Cognitive Changes

Severe Memory Loss

Severe Fatigue - unexplained by any other medical condition

Intermittent Fevers

Unintentional Weight Loss

Patient Name

Patient DOB

FINANCIAL RESPONSIBILITY:

Our office will contact your insurance company, and the necessary arrangements will be made for approval of the medication and administration. You may want to follow up with your insurance company also to be sure everything is covered. Our office does NOT provide a guarantee of coverage for any of these services. If coverage is not provided, YOU WILL BE RESPONSIBLE for any charges incurred for treatment and/or follow-up care.

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ANA (+) Screening for Systemic Lupus Erythematous

FINANCIAL RESPONSIBILITY:

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