Louisiana Lupus Foundation Member Survey

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Your responses will help the Louisiana Lupus Foundation provide support and resources to you through this worldwide health pandemic. We will discuss these at the upcoming group meeting. A prize will be sent to two random participants during the Sat., April 25 meeting. You will receive meeting details after you submit this form.We are here to support you.

What support group is nearest you?

Baton Rouge

Lafayette

Shreveport

New Orleans

Lake Charles

Alexandria

Clear selection

How long have you lived with a lupus diagnosis? *

Less than 5 years

6 -10 years

15 - 20 years

More than 20 years

What treatments or medicines are you currently taking or have taken to treat lupus in the last six months? (Check all that apply) *

Hydroxychloroquine/Plaquenil

Steroids, Prednisone (oral or shots)

Benlysta (infusions or shots)

Chemotherapy

Mycophenolat (Cellcept)

Acthar shots

Prescription pain medicine (Dilaudid, Tordal, Tramadol, Ketorlac, Naproxen, etc.)

Prescription vitamins (Vitamin B, Vitamin D, Potassium, Folic Acid, Iron, etc.)

Over the counter vitamins and supplements (Omega-3, Fish oil, fiber, multi-vitamins, melatonin)

Over the counter pain medicine (Tylenol, Advil, Asprin, etc.)

Homeopathic treatments (CBD, sea moss, moringa powder, pain ointments, essential oils)

Meditation, massages, or exercises

Azathioprine (Azasan, Imuran)

Other:

Required

Have you tested positive for coronavirus or COVID-19? *

Yes

I've taken the test but I don't have results.

Have you been treated for any of the following health issues in the last 6 months? *

Pneumonia

Bronchitis

Respiratory infection

Flu or Influenza

Asthma

Chest pains or pleurisy

Cold or cough

None of these conditions

Required

Are you in the home with someone who tested positive for COVID-19 / coronavirus? *

Yes

Did you get a flu shot this season? Either in 2019 or 2020. *

Yes

Since the coronavirus arrived in Louisiana, have you had any difficulty with one or more of the following? (Select all that apply) *

Seeing my doctor or specialist

Getting prescriptions fulfilled

Paying medical bills

Paying home bills

Getting food

Having increased pains or more disease complications

More anxiety, depression, feeling of loneliness, fears, or being overwhelmed more often

Required

On average, how many hours do you sleep a day? (Include naps) *

Are you currently in a flare? *

Yes

Yes. Slightly. It is manageable

Yes. Severely. I need to see my doctor

Other:

What helps you cope with the complications of lupus or bring you relief?

Family, friends, or having people to talk with

Massages, meditation, prayer, yoga, etc.

Blankets, pillows, heating pads, etc.

Music and dancing

Creative activities (sewing, painting, reading, cooking, puzzles, etc.)

Candles, incense, oils, etc.

Crying, shouting

Exercising, jogging, playing sports

Who lives with you? *

I live alone

Children under the age of 18

Young adults (children, grand children, family members)

Spouse, significant other

Another adult (child, family member, friend)

Required

Are you currently *

Retired

Employed and working at home

Employed but not working due to coronavirus

Unemployed due to coronavirus

Unemployed

Disabled and unable to work

Disabled but able to work part time

Do you have a living will or advanced directive?

Yes

Not to my knowledge

No but I will complete one soon.

Clear selection

Do you have any fears or concerns about living with lupus during this coronavirus spread that you would like to discuss with other members? *

Do you have any emergency needs? If so, provide as much detail as possible and include your contact information. *

Email address or phone number (optional)

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