Section 1: How often do you experience the following symptoms?
1.
Unexplained fevers, sweats, chills, or flushing
Never
Sometimes
Most of the time
All of the time
2.
Unexplained weight change ... loss or gain
Never
Sometimes
Most of the time
All of the time
3.
Fatigue, tiredness
Never
Sometimes
Most of the time
All of the time
4.
Unexplained hair loss
Never
Sometimes
Most of the time
All of the time
5.
Swollen glands
Never
Sometimes
Most of the time
All of the time
6.
Sore throat
Never
Sometimes
Most of the time
All of the time
7.
Testicular pain / Pelvic pain
Never
Sometimes
Most of the time
All of the time
8.
Unexplained mentrual irregularity
Never
Sometimes
Most of the time
All of the time
9.
Unexplained breast milk production, breast pain
Never
Sometimes
Most of the time
All of the time
10.
Irritable bladder or bladder dysfunction
Never
Sometimes
Most of the time
All of the time
11.
Secual dysfunction / loss of libido
Never
Sometimes
Most of the time
All of the time
12.
Upset stomach
Never
Sometimes
Most of the time
All of the time
13.
Change in bowel function (constipation or diarrhea)
Never
Sometimes
Most of the time
All of the time
14.
Chest pain or rib soreness
Never
Sometimes
Most of the time
All of the time
15.
Shortness of breath / cough
Never
Sometimes
Most of the time
All of the time
16.
Heart palpitations, pulse skips, heart block
Never
Sometimes
Most of the time
All of the time
17.
History of heart murmur or valve prolapse
Never
Sometimes
Most of the time
All of the time
18.
Joint pain or swelling
Never
Sometimes
Most of the time
All of the time
19.
Stiffness of the neck or back
Never
Sometimes
Most of the time
All of the time
20.
Muscle pain or cramps
Never
Sometimes
Most of the time
All of the time
21.
Twitching of the face or other muscles
Never
Sometimes
Most of the time
All of the time
22.
Headaches
Never
Sometimes
Most of the time
All of the time
23.
Neck cracks or neck stiffness
Never
Sometimes
Most of the time
All of the time
24.
Tingling, numbness, burning or stabbing sensations
Never
Sometimes
Most of the time
All of the time
25.
Facial paralysis (Bells Palsy)
Never
Sometimes
Most of the time
All of the time
26.
Eyes / Vision - Double, blurry
Never
Sometimes
Most of the time
All of the time
27.
Ears / Hearing - buzzing, ringing, ear pain
Never
Sometimes
Most of the time
All of the time
28.
Increased motion sickness, vertigo
Never
Sometimes
Most of the time
All of the time
29.
Lightheadedness, poor balance, difficulty walking
Never
Sometimes
Most of the time
All of the time
30.
Tremors
Never
Sometimes
Most of the time
All of the time
31.
Confusion, difficulty thinking
Never
Sometimes
Most of the time
All of the time
32.
Difficulty with concentration or reading
Never
Sometimes
Most of the time
All of the time
33.
Forgetfulness, poor short term memory
Never
Sometimes
Most of the time
All of the time
34.
Disorientation; getting lost, going to wrong places
Never
Sometimes
Most of the time
All of the time
35.
Difficulty with speech or writing
Never
Sometimes
Most of the time
All of the time
36.
Mood swings, irritability, depression
Never
Sometimes
Most of the time
All of the time
37.
Disturbed sleep - too much, too little, early awake
Never
Sometimes
Most of the time
All of the time
38.
Exaggerated symptoms or worse hangover from alcohol
Never
Sometimes
Most of the time
All of the time
Section 2: Most Common Lyme Symptoms Score
If you rated a "3" for all of the following questions in section 1:
#3 Fatigue
then 5 will be added to your final score
Section 3: Lyme Incidence Score
39.
You have had a tick bite with no rash or flu-like symptoms (3 points)
No
Yes
40.
You have had a tick bite, and Erythema migrans (bullseye rash) or undefined rash, followed by flu-like symptoms (5 points)
No
Yes
41.
You live in what is considered a Lyme endemic area (2 points)
No
Yes
42.
You have a family member diagnosed with Lyme and/or tick borne infections (1 point)
No
Yes
43.
You experience migratory muscle pain (4 points)
No
Yes
44.
You experience migratory joint pain (4 points)
No
Yes
45.
You experience tingling / burning / numbness that migrates and/or comes and goes (4 points)
No
Yes
46.
You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia (3 points)
No
Yes
47.
You have received a prior diagnosis of a specific autoimmune disorder (Lupus, MS, Rheumatoid Arthritis), or of a nonspecific autoimmune disorder (3 points)
No
Yes
48.
You have had a positive Lyme test (IFA, ELISA, Western Blot, PCR, and/or borrelia culture) (5 points)
No
Yes
Section 4: Overall Health Score
49.
Think about your overall physical health, for how many days during the past 30 days was your physical health not good?
0-5 days (1 point)
6-12 days (2 points)
13-20 days (3 points)
21-30 days (4 points)
50.
Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good?
0-5 days (1 point)
6-12 days (2 points)
13-20 days (3 points)
21-30 days (4 points)