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* 0 1 2 3 Fatigue, tiredness* 0 1 2 3 Unexplained hair loss* 0 1 2 3 Swollen glands* 0 1 2 3 Sore throat* 0 1 2 3 Testicular pain/pelvic pain* 0 1 2 3 Unexplained menstrual irregularity* 0 1 2 3 Unexplained breast milk production, breast pain* 0 1 2 3 Irritable bladder or bladder dysfunction* 0 1 2 3 Sexual dysfunction/loss of libido* 0 1 2 3 Upset stomach* 0 1 2 3 Change in bowel function (constipation or diarrhea)* 0 1 2 3 Chest pain or rib soreness* 0 1 2 3 Shortness of breath/cough* 0 1 2 3 Heart palpitations, pulse skips, heart block* 0 1 2 3 History of heart murmur or valve prolapse* 0 1 2 3 Joint pain or swelling* 0 1 2 3 Stiffness of the neck or back* 0 1 2 3 Muscle pain or cramps* 0 1 2 3 Twitching of the face or other muscles* 0 1 2 3 Tingling, numbness, burning or stabbing sensations* 0 1 2 3 Facial paralysis (bells palsy)* 0 1 2 3 Headaches* 0 1 2 3 Eyes/vision – double, blurry* 0 1 2 3 Ears/hearing – buzzing, ringing, ear pain* 0 1 2 3 Increased motion sickness, vertigo* 0 1 2 3 Lightheadedness, poor balance, difficulty walking* 0 1 2 3 Tremors* 0 1 2 3 Confusion, difficulty thinking* 0 1 2 3 Difficulty with concentration or reading* 0 1 2 3 Forgetfulness, poor short term memory* 0 1 2 3 Your 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
