Lupus (SLE) Medical Source Statement 2009-2025 free printable template

LUPUS (SHE) MEDICAL SOURCE STATEMENT From: Re: (Name of Patient) (Social Security No.) Please answer the following questions concerning your patients impairments. Attach relevant treatment notes,

How to fill out Lupus SLE Medical Source Statement

How to fill out Lupus (SLE) Medical Source Statement

1. Begin by gathering relevant medical records related to the patient's lupus diagnosis.
2. Identify the healthcare provider who will complete the statement, ensuring they have experience in treating lupus (SLE).
3. Fill in the patient's personal information, including name, date of birth, and contact details.
4. Detail the patient's medical history regarding lupus, including symptoms, flare-ups, and treatments received.
5. Assess and document the patient's current functional limitations caused by lupus.
6. Include information on any medications the patient is currently taking for lupus management.
7. Describe how lupus impacts the patient's daily activities and ability to work.
8. Sign and date the Medical Source Statement, providing contact information for follow-up.

Who needs Lupus (SLE) Medical Source Statement?

1. Individuals diagnosed with lupus (SLE) who are applying for disability benefits or accommodations.
2. Healthcare providers who need to support a patient's claim for appropriate care or treatment adjustments.
3. Legal representatives working on cases involving disability claims related to lupus.

People Also Ask about

When was SLE first diagnosed?

The first clear description of lupus erythematosus was by Biett and was reported by his student Cazenave under the term erythema centrifugum in 1833. In 1846 Hebra, under the name of Seborrhea Congestiva described disc-shaped patches and introduced the butterfly simile for the malar rash.

What is the cause of SLE?

Further, several drugs such as the sulfa-drugs are well known to cause flares in patients with SLE. Ultraviolet rays and sun exposure lead to increased cell apoptosis and are well-known triggers for SLE. Several viral infections have been implicated, and the underlying mechanism is thought to be molecular mimicry.

Why SLE was not diagnosed earlier?

The initial symptoms of systemic lupus erythematosus are often nonspecific and mimic other medical conditions, increasing the risks for diagnostic delay. The heterogeneity of possible manifestations makes early diagnosis and subsequent disease management more difficult and can delay effective treatment.

What are the characteristics of SLE?

SLE may first appear as extreme tiredness (fatigue), a vague feeling of discomfort or illness (malaise), fever, loss of appetite, and weight loss. Most affected individuals also have joint pain, typically affecting the same joints on both sides of the body, and muscle pain and weakness. Skin problems are common in SLE.

How quickly is lupus diagnosed?

On average, it takes nearly six years for people with lupus to be diagnosed, from the time they first notice their lupus symptoms. A majority (63%) of people with lupus surveyed report being incorrectly diagnosed.

What is stage 4 lupus?

Class 4, or diffuse lupus nephritis Class 4 involves damage to more than half of the glomerulus. A person will have high blood pressure. They may require dialysis as kidney function begins to worsen.

What is the survival rate of SLE patients?

With close follow-up and treatment, 80-90% of people with lupus can expect to live a normal life span. It is true that medical science has not yet developed a method for curing lupus, and some people do die from the disease. However, for the majority of people living with the disease today, it will not be fatal.

What is the severity of SLE?

Systemic lupus erythematosus (SLE) is a severe, complex, multi-system autoimmune rheumatic disease. It is most prevalent among women of childbearing age. Approximately 20% of cases begin during childhood, usually after puberty,4–6 and published data suggest a further 10–20% present after the age of 50 years.

How do you determine the severity of SLE?

The LFA-REAL specifically assigns equal lengths for each scale for mild, moderate and severe disease. Thus, mild disease is scored between 0 and 1, moderate between 1 and 2 and severe between 2 and 3.

For pdfFiller’s FAQs

How do I modify my Lupus SLE Medical Source Statement in Gmail?

In your inbox, you may use pdfFiller's add-on for Gmail to generate, modify, fill out, and eSign your Lupus SLE Medical Source Statement and any other papers you receive, all without leaving the program. Install pdfFiller for Gmail from the Google Workspace Marketplace by visiting this link. Take away the need for time-consuming procedures and handle your papers and eSignatures with ease.

How can I send Lupus SLE Medical Source Statement for eSignature?

When you're ready to share your Lupus SLE Medical Source Statement, you can send it to other people and get the eSigned document back just as quickly. Share your PDF by email, fax, text message, or USPS mail. You can also notarize your PDF on the web. You don't have to leave your account to do this.

Can I create an electronic signature for the Lupus SLE Medical Source Statement in Chrome?

Yes, you can. With pdfFiller, you not only get a feature-rich PDF editor and fillable form builder but a powerful e-signature solution that you can add directly to your Chrome browser. Using our extension, you can create your legally-binding eSignature by typing, drawing, or capturing a photo of your signature using your webcam. Choose whichever method you prefer and eSign your Lupus SLE Medical Source Statement in minutes.

What is Lupus (SLE) Medical Source Statement?

The Lupus (SLE) Medical Source Statement is a document provided by healthcare professionals that outlines the medical condition of a patient diagnosed with Systemic Lupus Erythematosus (SLE). It details the patient's symptoms, limitations, and how the illness affects their daily functioning.

Who is required to file Lupus (SLE) Medical Source Statement?

The Lupus (SLE) Medical Source Statement is typically required to be filed by healthcare providers who are treating patients diagnosed with Systemic Lupus Erythematosus. This may include rheumatologists, primary care physicians, or any other specialist involved in the patient's care.

How to fill out Lupus (SLE) Medical Source Statement?

To fill out a Lupus (SLE) Medical Source Statement, healthcare providers should accurately document the patient's diagnosis, symptoms, treatment plans, prognosis, and any functional limitations that the lupus condition imposes on the patient's ability to work or engage in daily activities.

What is the purpose of Lupus (SLE) Medical Source Statement?

The purpose of the Lupus (SLE) Medical Source Statement is to provide objective medical evidence regarding a patient's condition. This is often needed for disability claims, insurance purposes, or to assist with accommodations in the workplace or academic settings based on the impact of the disease.

What information must be reported on Lupus (SLE) Medical Source Statement?

The information that must be reported on the Lupus (SLE) Medical Source Statement includes the patient's medical history, current symptoms, specific diagnoses, treatment regimens, the effectiveness of treatment, and any physical or psychological limitations that the patient experiences as a result of lupus.