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Lyme Disease Questionnaire

"*" indicates required fields

The Horowitz Lyme-MSIDS Questionnaire is not intended to replace the advice of your own physician or other medical professional. You should consult a medical professional in matters relating to health, and individuals are solely responsible for their own health care decisions regarding the use of this questionnaire. It is intended for informational purposes only and not for self-treatment or diagnosis.

SECTION 1: SYMPTOM FREQUENCY SCORE

1. Unexplained fevers, sweats, chills, or flushing*
2. Fatigue, tiredness*
3. Unexplained weight change; loss or gain*
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 neck or back*
20. Muscle pain or cramps*
21. Twitching of the face or other muscles*
22. Headaches*
23. Neck cracks or neck stiffness*
24. Tingling, numbness, burning, or stabbing sensations*
25. Facial paralysis (Bell’s palsy)*
26. Eyes/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 or worse hangover from alcohol*

SECTION 2: MOST COMMON LYME SYMPTOMS SCORE

39. Fatigue*
40. Forgetfulness, poor short-term memory*
41. Joint pain or swelling*
42. Tingling, numbness, burning, or stabbing sensations*
43. Disturbed sleep: too much, too little, early awakening*

SECTION 3: LYME INCIDENCE SCORE

please select "True" for each of the following statements you can agree with:
44. You have had a tick bite with no rash or flulike symptoms.
45. You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms.
46. You live in what is considered a Lyme-endemic area.
47. You have a family member who has been diagnosed with Lyme and/or other tick-borne infections.
48. You experience migratory muscle pain.
49. You experience migratory joint pain.
50. You experience tingling/burning/numbness that migrates and/or comes and goes.
51. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia.
52. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder.
53. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture).

SECTION 4: OVERALL HEALTH SCORE

54. Thinking about your overall physical health, for how many of the past thirty days was your physical health not good?*
55. Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good?*

SECTION 5: PATIENT DETAILS

Name*
Consent
This field is for validation purposes and should be left unchanged.