This is a questionnaire to determine the probability of your having Lyme disease and other tick borne disorders. Think about how you have been feeling over the previous month and how often you have been bothered by the following:Name* First Last Section 1 Enter numbers only: 0 - Never 1 - Sometimes2 - Almost all the time 3 - All of the timeUnexplained fevers, sweats, chills, or flushing*0123Fatigue, tiredness*0123Unexplained hair loss*0123Swollen glands*0123Sore throat*0123Testicular pain/pelvic pain*0123Unexplained menstrual irregularity*0123Unexplained breast milk production, breast pain*0123Irritable bladder or bladder dysfunction*0123Sexual dysfunction/loss of libido*0123Upset stomach*0123Change in bowel function (constipation or diarrhea)*0123Chest pain or rib soreness*0123Shortness of breath/cough*0123Heart palpitations, pulse skips, heart block*0123History of heart murmur or valve prolapse*0123Joint pain or swelling*0123Stiffness of the neck or back*0123Muscle pain or cramps*0123Twitching of the face or other muscles*0123Tingling, numbness, burning or stabbing sensations*0123Facial paralysis (bells palsy)*0123Headaches*0123Eyes/vision – double, blurry*0123Ears/hearing – buzzing, ringing, ear pain*0123Increased motion sickness, vertigo*0123Lightheadedness, poor balance, difficulty walking*0123Tremors*0123Confusion, difficulty thinking*0123Difficulty with concentration or reading*0123Forgetfulness, poor short term memory*0123Your score from section 1Section 2 Now, please check off each incident you can answer yes to with the following questions: 1. You have had a tick bite with no rash or flu-like symptoms. 2. You have had a tick bite, an Erythema migrans or undefined rash, followed by flu-like symptoms. 3. You live in what is considered a Lyme endemic area. 4. You have a family member diagnosed with Lyme and/or tick borne infections. 5. You experience migratory muscle pain. 6. You experience migratory joint pain. 7. You experience tingling/burning/numbness that migrates and/or comes and goes. 8. You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia. 9. You have received a prior diagnosis of a non specific autoimmune disorder (Lupus, MS, Rheumatoid Arthritis). 10. You have had a positive Lyme test (ELISA, Western Blot, PCR). Your score from Section 2Score from Section 1 + Section 2 (This is your Ongoing Score)Section 3 Thinking about your overall physical health, for how many days during the past 30 days was your physical health not good? 0 – 5 days 6 – 12 days 13 – 20 days 21 – 30 days Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good? 0 – 5 days 6 – 12 days 13 – 20 days 21 – 30 days Your points from Section 3+ Ongoing ScoreLastly, check the box below if on Section 1 you rated a ‘3’ for ALL of the following: Fatigue Forgetfulness, poor short term memory Joint pain or Swelling Tingling, numbness, burning or stabbing sensations Disturbed sleep – Too Much, Too Little, Early Awake I Rated "3" in Section 1 for all the above symptoms Yes Final ScoreNow please take your final score and compare it to the scale used by Dr. Horowitz 0 – 20 Tick Borne Illness not likely 21-45 Tick Borne Illness possible 46 and above Tick Borne Illness highly likely
