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Talk To Your Doctor: CAPS Symptoms Checklist

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Complete this Cryopyrin-Associated Periodic Syndromes (CAPS) symptoms checklist if you are having unexplained symptoms. You can also complete it for your child or other loved one. Please read each question and choose the response that best describes the unexplained symptoms. Then share the results with the doctor.

These symptoms may be a sign that you have CAPS, a group of rare diseases. CAPS often run in families, so find out if your relatives are experiencing similar symptoms, too.

This symptoms checklist is not intended to offer medical advice or make a diagnosis. If you have questions or concerns about your health, please talk to your doctor. Only a doctor can determine what may be causing your symptoms and whether or not you have CAPS.

*All fields required.

1. Do you often break out in a rash that looks like hives or red spots?

Yes

No

2. When were these symptoms first noticed? (check one)

At birth/during first 6 months

Early childhood

Age 15 years or older

Not sure/don’t know

3. Do you get daily or recurring fever or chills?

Yes

No

4. Do you get pain or swelling of the hands, feet, knees, ankles, wrists, or elbows?

Yes

No

5. Do any of these symptoms get worse during the day?

Yes

No

6. During these attacks, do you also have any of the following symptoms? (Check all that apply)

Tiredness or lack of energy

Eye pain or redness

Headaches

None of the above

7. Have you developed any of the following? (Check all that apply)

Hearing loss or deafness

Developmental delays

Joint damage or deformity

Kidney problems

Vision loss or blurred vision

Inflammation around the brain

None of the above

8. Does exposure to cold or a drop in temperature trigger symptoms?

Yes

No

9. How long after exposure to cold do your symptoms usually start? (check one)

Right away

30 minutes or less

More than 30 minutes

Does not apply

10. Do other family members have similar symptoms?

Yes

No

Not sure/don’t know