FORM 4 (Optional): Lyme Disease Questionnaire (Complete if you believe you have tick borne illness)

Lyme/Tick-Borne Illness Questionnaire

If you believe you have Lyme Disease or another tick-borne infection or have been previously diagnosed with a tick-borne disease, please complete this form.
Name*
Date*

MonthDayYear
Date of Birth*

MonthDayYear
Current Age*
Address*
Phone Number
Please enter a valid phone number.
Email
example@example.com
SECTION 1: SYMPTOM FREQUENCY SCORE

Choose one answer per symptom. You will be assigned 0 points for no symptoms up to 3 points for severe symptoms.
1. Unexplained fever, sweats, chills, or flushing*

NoneMildModerateSevere
2. Unexplained weight change; loss or gain*

NoneMildModerateSevere
3. Fatigue, tiredness*

NoneMildModerateSevere
4. Unexplained hair loss*

NoneMildModerateSevere
5. Swollen glands*

NoneMildModerateSevere
6. Sore throat*

NoneMildModerateSevere
7. Testicular or pelvic pain*

NoneMildModerateSevere
8. Unexplained menstrual irregularity*

NoneMildModerateSevere
9. Unexplained breast milk production; breast pain*

NoneMildModerateSevere
10. Irritable bladder or bladder dysfunction*

NoneMildModerateSevere
11. Sexual dysfunction or loss of libido*

NoneMildModerateSevere
12. Upset stomach*

NoneMildModerateSevere
13. Change in bowel function (constipation or diarrhea)*

NoneMildModerateSevere
14. Chest pain or rib soreness*

NoneMildModerateSevere
15. Shortness of breath or cough*

NoneMildModerateSevere
16. Heart palpitations, pulse skips, heart block*

NoneMildModerateSevere
17. History of a heart murmur or valve prolapse*

NoneMildModerateSevere
18. Joint pain or swelling*

NoneMildModerateSevere
19. Stiffness of the back*

NoneMildModerateSevere
20. Muscle pain or cramps*

NoneMildModerateSevere
21. Twitching of the face or other muscles*

NoneMildModerateSevere
22. Headaches*

NoneMildModerateSevere
23. Neck cracks or stiffness*

NoneMildModerateSevere
24. Tingling, numbness, burning, or stabbing sensations*

NoneMildModerateSevere
25. Facial paralysis (Bell's palsy)*

NoneMildModerateSevere
26. Eye/vision: double, blurry*

NoneMildModerateSevere
27. Ears/hearing: buzzing, ringing, ear pain*

NoneMildModerateSevere
28. Increased motion sickness, vertigo*

NoneMildModerateSevere
29. Light-headedness, poor balance, difficulty walking*

NoneMildModerateSevere
30. Tremors*

NoneMildModerateSevere
31. Confusion, difficulty thinking*

NoneMildModerateSevere
32. Difficulty with concentration or reading*

NoneMildModerateSevere
33. Forgetfulness, poor short-term memory*

NoneMildModerateSevere
34. Disorientation: getting lost; going to wrong places*

NoneMildModerateSevere
35. Difficulty with speech or writing*

NoneMildModerateSevere
36. Mood swings, irritability, depression*

NoneMildModerateSevere
37. Disturbed sleep: too much, too little, early awakening*

NoneMildModerateSevere
38. Exaggerated symptoms of worse hangover from alcohol*

NoneMildModerateSevere
Total of Section 1
SECTION 2: MOST COMMON LYME/TBI SYMPTOMS SCORE
BASED ON YOUR ANSWERS IN SECTION 1 which of the following did you mark as "Severe"? Check all that apply.*

Fatigue, tirednessJoint pain or swellingForgetfulness, poor short-term memoryDisturbed sleep: too much, too little, early awakeningTingling, numbness, burning, or stabbing sensations
Total of Section 2
SECTION 3: LYME INCIDENCE SCORE

Mark each statement True or False. You will be assigned 3 points for true anwers in section 3A and 5 points for true answers in section 3B.
You have had a tick bite with no rash or flulike symptoms.*

TrueFalse
You have had a tick bite, an erythema migraines, or an undefined rash, followed by flulike symptoms.*

TrueFalse
You live in what is considered a Lyme-endemic area.*

TrueFalse
You have a family member who has been diagnosed with Lyme and/or other tick- borne infections.*

TrueFalse
Total of Section 3A
You experience migratory muscle pain.*

TrueFalse
You experience migratory joint pain.*

TrueFalse
You experience tingling/ burning/ numbness that migrates and/or comes and goes.*

TrueFalse
You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia.*

TrueFalse
You have received a prior diagnosis of a specific autoimmune disorder (Lupus, MS or Rheumatoid Arthritis) or of a nonspecific autoimmune disorder.*

TrueFalse
You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or Borrelia culture).*

TrueFalse
Total of Section 3B
Total of Section 3
SECTION 4: OVERALL HEALTH SCORE

You will be assigned a higher score for a longer period of illness
Thinking about your overall physical health, for how many of the past 30 days was your physical health unwell?*

0-5 days6-12 days13-20 days21-30 days
Thinking about your overall mental health, for how many of the past 30 days was your mental health unwell?*

0-5 days6-12 days13-20 days21-30 days
Total for Section 4
Final Total Score
Final Score
INTERPRETATION:

If you scored under 21, you are not likely to have a tick-borne disorder.

If you scored between 21 and 45, you possibly have a tick-borne disorder.

If you scored 46 or more, you have a high probability of a tick-borne disorder.
SECTION 5: YOUR ILLNESS
How long have you been sick?*

<1 year1-2 years3-5 years6-10 year>10 years
Have you been:*

Continuously illHave had periods of recovery and relapse
Rate your overall health status including level of pain, fatigue, neurological or othersymptoms on a scale of 1-10 with 1=Healthy and 10=Severely ill*

1

2

3

4

5

6

7

8

9

10

1 is Healthy, 10 is Severely ill
What is your work status? Check one.*

Working full time at an officeWorking part time at an officeWorking full time at homeWorking part time at homeNot working due to health problemsNot working for other reasons
Have you been declared disabled and are receiving any disability services(insurance, financial support, etc.) *
What infections have you been either diagnosed with or are suspected based on clinical symptoms? Check all that apply.*

Borrelia (Lyme Disease)BartonellaBabesiaOther bacteriaMycoplasmaVirusesParasitesFungi and Yeast (Candida and other species)None of theseOther
Please give specific species of Babesia or n/a.*
Please give specific species of other bacteria or n/a.*
Please give specific species of other viruses or n/a.*
Please give specific species of other parasites or n/a.*
Please give specific species of fungi and yeast or n/a.*
Antibiotic Usage:*

Currently taking antibiotics for the first timeHave taken antibiotics in the past and am not on them nowHave taken antibiotics, stopped for a while, then resumed and am on them nowHaven't taken antibiotics
Method of delivery?*

Taking or have taken only oral antibioticsTaking or have taken both IV and oral antibiotics
How long have you been taking or took antibiotics?*
Did you receive any IV antibiotics?*

YesNo
How long?*
Did you feel you got any benefit from taking antibiotics?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
Have you ever used any non-antibiotic therapies to treat your condition?*

YesNo
Check all therapies that apply.*

HerbalsHomeopathicDetoxification Therapies (colon therapy, chelation, glutathione, fasting)Hyperbaric OxygenHigh Dose IV Vitamin COther
Did you feel you got any benefit from herbals?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
Did you feel you got any benefit from homeopathic therapy?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
Did you feel you got any benefit from detoxification therapy?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
Did you feel you got any benefit from hyperbaric oxygen therapy?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
Did you feel you got any benefit from high dose IV vitamin C?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
Did you feel you got any benefit from this other therapy?*

1

2

3

4

5

6

7

8

9

10

1 is No Benefit, 10 is Great Benefit
List any pain medications you are currently taking or input "N/A"*
Have you ever had lab tests showing liver problems (elevated liver enzymes)?*

YesNo
Details of liver problems*
Check any secondary problems that you are experiencing beyond the typical tick-borne infection symptoms:*

Women’s hormonal issues (PMS, cramping, exaggerated peri-menopausal)Neuropathy (numbness and tingling in your extremities)Digestive problems – indigestion, heartburn, gas, bloating, abnormal BM’s, etc.Changes in vision or hearingYeast overgrowth (rectal itching, carb cravings, nail fungus, jock itch, discharge)None of the above
Check whichever applies regarding dental amalgam fillings*

I have never had any amalgam fillings.I currently have amalgam fillings.I used to have amalgam fillings and have had them replaced with non-toxicmaterials or crowns.
How many fillings do you currently have?*
Check the type of dentist who did the work*

A Biological Dentist who uses protective equipment to preventmercury from entering the body during the procedureMy family dentist who did not use any protective equipment that Iwas aware of.
Did you find this dentist through the IAOMT (International Association of Oral Medicine and Toxicology)?*

YesNo
Please describe any adverse effects from the removal of your amalgam fillings or input "N/A"*
Should be Empty:

Lyme/Tick-Borne Illness Questionnaire

SECTION 1: SYMPTOM FREQUENCY SCORE

SECTION 2: MOST COMMON LYME/TBI SYMPTOMS SCORE

SECTION 3: LYME INCIDENCE SCORE

SECTION 4: OVERALL HEALTH SCORE

Final Total Score

SECTION 5: YOUR ILLNESS