Patient Navigation Intake Questionnaire

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Lupus Foundation of America, Indiana Chapter

What is your living situation?

Alone

With Partner

With Children

With Parents

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What is work status?

Full-Time

Part-Time

Not working

Disabled

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What is your insurance status?

Medicaid

Medicare

Private Insurance

Self-Pay

Employer Sponsored Insurance

No Health Insurance

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How is your lupus doing?

Not active at all

Mildly active

Very active

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How often does your lupus affect your day to day?

Frequently

Occasionally

Rarely

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How often does money affect your means to make and attend doctor's appointments?

Frequently

Occasionally

Rarely

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How often does money affect your means to fill and take your prescriptions?

Frequently

Occasionally

Rarely

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I need help assistance with prescription costs and/or co-pays.

1 (Very low need)

5 (Very high need)

Other:

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How often does transportation affect your means to fill your prescriptions?

Frequently

Occasionally

Rarely

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How often does transportation affect your means to make and go to doctor's appointments ?

Frequently

Occasionally

Rarely

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I need help with transportation.

1 (Very low need)

5 (Very high need)

Other:

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How often do you take your medications as prescribed?

Always

More than 80% of the time

Between 60-80% of the time

Less than 60% of the time

Never because it does not help me

I am currently not on medication to treat my lupus

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How often does your mood affect you taking your medications?

Frequently

Occasionally

Rarely

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How often does your mood affect your attendance at appointments?

Frequently

Occasionally

Rarely

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How well do you understand your diagnosis?

Very well

Well

Fairly well

Not well

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I need help understanding my diagnosis.

1 (Very low need)

5 (Very high need)

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I need assistance of a support group.

1 (Very low need)

5 (Very high need)

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How often have you missed doctor's appointment in the last year?

More than twice

Once or twice

Never

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If you answered once or more to the above question, please explain why you missed the doctor's appointment?

How often have you visited the emergency room in the last year?

More than twice

Once or twice

Never

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If you answered once or more to the above question, please explain the reason you visited the emergency room.

How often have you been admitted to the hospital in the last year?

Greater than 4 times

Between 3 and 4 times

Twice

Once

Never

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If you answered once or more to the above question, was your lupus active at the time?

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