Lupus Foundation of America Inc.

Lupus Research Registry

The Lupus Research Registry allows people to register to receive email alerts of clinical trials in their area based on the information provided by the user at registration.

To join the registry, please complete the form below and submit your registration. Our Lupus Research Registry Privacy Statement is available for review.

The Lupus Research Registry is part of LFA’s ongoing efforts to advance the science and medicine of lupus and help speed development and approval of new, safer and more tolerable treatments for lupus. The registry ensures the community is informed and engaged in the quest for new treatments and ultimately a cure for lupus.

Please provide your information below:

If you have previously registered, please to prepopulate your information.

Title:

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First Name: Required

Middle Name:

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Last Name: Required

Suffix:

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Email: Required

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Street 1: Required

Street 2:

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City: Required

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State / Province: Required

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ZIP / Postal Code: Required

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Country: Required

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Gender: Required

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Date of Birth: Required

Yes, I would like to receive e-mail from Lupus Foundation of America

Yes, I would like to receive postal mail from Lupus Foundation of America

Remember me. What's this?

Please enter a user name and password for logging in when you return. You can use this password to update your information or receive personalized content.

*	User Name: Required		5 to 60 characters
*	Password: Required		5 to 20 characters
*	Repeat Password: Required

Question - Required - *I would like to receive email and/or postal mail from the LFA chapter in my area.

Question - Required - *Primary language spoken at home:

Question - Not Required - If you chose Other, please explain:

Question - Not Required - Ethnicity:

Question - Required - *What form of lupus do you have?

Question - Not Required - If you were first diagnosed with cutaneous lupus, has the disease progressed to systemic lupus?

Question - Not Required - Year diagnosed:

Question - Not Required - How long did it take for you to obtain your lupus diagnosis?

Question - Not Required - Number of physicians seen before diagnosis made

Question - Not Required - What type of physician or health care provider diagnosed you?

Question - Not Required - If you chose Other, please explain:

Question - Not Required - Were you diagnosed with mild, moderate or severe lupus at the time of diagnosis

Question - Not Required - When did your last lupus flare occur?

Question - Required - *Approximately how many times per year do you experience lupus flares?

In the section below please note the types of medication and treatments you are currently on. Please check all that apply.

Question - Required - *Anti-inflammatories (aspirin, Tylenol, Motrin, Naprosyn, Relafen, Celbrex, etc)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Corticosteroids (cortisone, or steroids for example)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Antimalarials (Plaquenil, for example)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Immunosuppressives (immune modulators such as Cytoxan and Imuran, etc)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Anticoagulants (aspirin, Coumadin, for example)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Biologics (Orencia, for example)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Hormones/birth control

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Monoclonal Antibodies (Rituxan, for example)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Organ transplant anti-rejection drugs (CellCept, for example)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Required - *Topical Immunomodulators (Protopic and/or Elidel)

Question - Not Required - If you chose Yes, how long have you been on this treatment?

Question - Not Required - Other?

Question - Not Required - If you chose Other, how long have you been on this treatment?

Question - Not Required - Types of medication have been on in the past:

	Anticoagulents
	Anti-inflammatories
	Antimalarials
	Biologics
	Corticosteroids
	Hormones/birth control
	Immunosuppressives
	Monoclonal antibodies
	Organ transplant anti-rejection drugs
	Topical immunomodulators
	Other

Question - Required - *Do you have any medication allergies?

Question - Not Required - Do you have any organ involvement? If so, which organ(s)?

	Brain (Central Nervous System)
	GI System (liver, pancreas, etc)
	Heart
	Kidneys
	Lungs
	Skin

Question - Not Required - In addition to lupus, do you have any other illnesses or conditions?

	Fibromyalgia
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other

Question - Required - *Have you ever participated in a clinical trial?

Question - Not Required - If you have not participated, would you consider participation?

Question - Not Required - If you would not consider participation, why not?

Question - Required - *Would you be interested in learning more about clinical trials in your area?

Question - Not Required - If yes, what is the best way to contact you?

Question - Not Required - How far would you be willing to travel?

Do any other individuals in your family have either lupus or another autoimmune disease?

Question - Required - *Mother

Question - Not Required - If so, which one(s)?

	Fibromyalgia
	Lupus
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other

Question - Required - *Father

Question - Not Required - If so, which one(s)?

	Fibromyalgia
	Lupus
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other

Question - Required - *Sister

Question - Not Required - If so, which one(s)?

	Fibromyalgia
	Lupus
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other

Question - Required - *Brother

Question - Not Required - If so, which one(s)?

	Fibromyalgia
	Lupus
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other

Question - Required - *Child

Question - Not Required - If so, which one(s)?

	Fibromyalgia
	Lupus
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other

Question - Required - *Other family member

Question - Not Required - If so, which one(s)?

	Fibromyalgia
	Lupus
	Mixed Connective Tissue Disease
	Polymyositis-Dermatomyositis
	Raynauds
	Rheumatoid arthritis
	Scleroderma
	Sjogren's
	Other