Lyme Disease Questionnaire (38 Pt Sxs Checklist)

1. Do you have unexplained fevers, sweats, chills, or flushing?

2. Do you have unexplained weight change.....loss or gain?

*Note: You will need your answer to the question below for later in the questionnaire.*

3. Do you have fatigue, or experience tiredness frequently?

4. Do you have unexplained hair loss?

5. Do you have swollen glands?

6. Do you get sore throats?

7. Do you get testicular pain (males) / pelvic pain (females)?

8. Do you have unexplained menstrual irregularity?

9. Do you have unexplained breast milk production, breast pain?

10. Do you have irritable bladder or bladder dysfunction?

11. Do you have sexual dysfunction / loss of libido?

12. How often do you have an upset stomach?

13. Do you have a change in bowel function (constipation or diarrhea)?

14. Do you have chest pain or rib soreness?

15. Do you have shortness of breath / cough?

16. Do you have heart palpitations, pulse skips, heart block?

17. Do you have a history of heart murmur or valve prolapse?

*Note: You will need your answer to the question below for later in the questionnaire.*

18. Do you have joint pain or swelling?

19. Do you have stiffness of the neck or back?

20. Do you have muscle pain or cramps?

21. Do you get twitching of the face or other muscles?

22. How often do you have headaches?

23. Do you hear your neck crack or do you have neck stiffness?

*Note: You will need your answer to the question below for later in the questionnaire.*

24. Do you get tingling, numbness, burning or stabbing sensations?

25. Do you have facial paralysis (Bells palsy)?

26. Does your eyes/vision – double and/or are they blurry at times?

27. Do you experience ears/hearing – buzzing, ringing, ear pain?

28. Do you experience increased motion sickness, vertigo?

29. Do you experience lightheadedness, poor balance, difficulty walking?

30. Do you experience tremors?

31. Do you experience confusion, difficulty thinking?

32. Do you have difficulty with concentration or reading?

*Note: You will need your answer to the question below for later in the questionnaire.*

33. Do you experience forgetfulness, and/or have poor short term memory?

34. Do you experience disorientation; getting lost, going to wrong places?

35. Do you have difficulty with speech or writing?

36. Do you have mood swings, irritability, depression?

*Note: You will need your answer to the question below for later in the questionnaire.*

37. Do you experience disturbed sleep – too much, too little, early awake?

38. Do you experience exaggerated symptoms or worse hangover from alcohol?

39. You have had a tick bite with no rash or flu-like symptoms?

40. You have had a tick bite, an erythema migrans (bullseye rash) or undefined rash, followed by flu-like symptoms?

41. You live in what is considered a Lyme endemic area?

42. You have a family member diagnosed with Lyme and/or tick borne infections?

43. You experience migratory (moving around your body) muscle pain?

44. You experience migratory (moving around your body) joint pain?

45. You experience tingling/burning/numbness that migrates and/or comes and goes?

46. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia?

47. You have received a prior diagnosis of a non-specific autoimmune disorder (Lupus, MS, Rheumatoid arthritis)?

48. You have had a positive Lyme test (ELISA, Western Blot, PCR)?

49. Thinking about your overall physical health, for how many days during the past 30 days was your physical health not good?

50. Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good?

51. Lastly, did you answer  "All of the time (3)" for ALL five of the questions (3, 18, 24, 33, and 37) from earlier (these are the ones I wrote that you will need your answers for later in the questionnaire)? Scroll back up and check your answers to those questions so that you can answer this question.