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.
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  • Format: (000) 000-0000.

  • 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*
  • 2. Unexplained weight change; loss or gain*
  • 3. Fatigue, tiredness*
  • 4. Unexplained hair loss*
  • 5. Swollen glands*
  • 6. Sore throat*
  • 7. Testicular or pelvic pain*
  • 8. Unexplained menstrual irregularity*
  • 9. Unexplained breast milk production; breast pain*
  • 10. Irritable bladder or bladder dysfunction*
  • 11. Sexual dysfunction or loss of libido*
  • 12. Upset stomach*
  • 13. Change in bowel function (constipation or diarrhea)*
  • 14. Chest pain or rib soreness*
  • 15. Shortness of breath or cough*
  • 16. Heart palpitations, pulse skips, heart block*
  • 17. History of a heart murmur or valve prolapse*
  • 18. Joint pain or swelling*
  • 19. Stiffness of the back*
  • 20. Muscle pain or cramps*
  • 21. Twitching of the face or other muscles*
  • 22. Headaches*
  • 23. Neck cracks or stiffness*
  • 24. Tingling, numbness, burning, or stabbing sensations*
  • 25. Facial paralysis (Bell's palsy)*
  • 26. Eye/vision: double, blurry*
  • 27. Ears/hearing: buzzing, ringing, ear pain*
  • 28. Increased motion sickness, vertigo*
  • 29. Light-headedness, poor balance, difficulty walking*
  • 30. Tremors*
  • 31. Confusion, difficulty thinking*
  • 32. Difficulty with concentration or reading*
  • 33. Forgetfulness, poor short-term memory*
  • 34. Disorientation: getting lost; going to wrong places*
  • 35. Difficulty with speech or writing*
  • 36. Mood swings, irritability, depression*
  • 37. Disturbed sleep: too much, too little, early awakening*
  • 38. Exaggerated symptoms of worse hangover from alcohol*

  • 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.*

  • 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.*
  • You have had a tick bite, an erythema migraines, or an undefined rash, followed by flulike symptoms.*
  • You live in what is considered a Lyme-endemic area.*
  • You have a family member who has been diagnosed with Lyme and/or other tick- borne infections.*
  • You experience migratory muscle pain.*
  • You experience migratory joint pain.*
  • You experience tingling/ burning/ numbness that migrates and/or comes and goes.*
  • You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia.*
  • You have received a prior diagnosis of a specific autoimmune disorder (Lupus, MS or Rheumatoid Arthritis) or of a nonspecific autoimmune disorder.*
  • You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or Borrelia culture).*

  • 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?*
  • Thinking about your overall mental health, for how many of the past 30 days was your mental health unwell?*

  • Final Total 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?*
  • Have you been:*
  • What is your work status? Check one.*
  • What infections have you been either diagnosed with or are suspected based on clinical symptoms? Check all that apply.*
  • Antibiotic Usage:*
  • Method of delivery?*
  • Did you receive any IV antibiotics?*
  • Have you ever used any non-antibiotic therapies to treat your condition?*
  • Check all therapies that apply.*
  • Have you ever had lab tests showing liver problems (elevated liver enzymes)?*
  • Check any secondary problems that you are experiencing beyond the typical tick-borne infection symptoms:*
  • Check whichever applies regarding dental amalgam fillings*
  • Check the type of dentist who did the work*
  • Did you find this dentist through the IAOMT (International Association of Oral Medicine and Toxicology)?*
  • Should be Empty: