Questions for Lupus study
Please answer the below questions and then continue to the calendar to schedule an appointment with us!
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Age
*
1. Kindly document the following information:
*
2. Have you been diagnosed with Lupus in the past 6 months?
*
Yes
No
3. Do you have any upcoming planned procedures or surgeries in the next few months?
*
Yes
No
4. Do you have any history of Herpes infection?
*
Yes
No
5. Are you facing any other major diseases other than Lupus?
*
Yes
No
5a. What disease?
6. Do you have any history of cancer (other than skin cancer)?
*
Yes
No
77 Pond Avenue, Brookline, MA 02445- Suite 205C
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CrioID
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