Lyme - Tick Borne Disease - Initial Symptom Check List
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4Lyme - Tick Borne Disease - Initial Symptom Check List
Name: __________________________________________
Date: ____________________
Risk Profile: (Please check all that apply)
Tick infested area ___ Frequent Outdoor Activities___ Hiking___ Fishing___ Camping ___ Gardening ___
Hunting ___ Ticks noted on pets ___
Do you remember being bitten by a tick? No ___ Yes___ When? _______
Do you remember having a “bulls eye rash”? No___ Yes___
Any other rash? No____ Yes____
Do you now have or have you recently had any of the following symptoms? Check all yes answers
1. _____Unexplained fevers, 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 pain/ pelvic pain
8. _____Unexplained menstrual irregularity
9. _____Unexplained 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, cough
16. _____Heart palpitations, pulse skips, heart block
17. _____Any history of a heart murmur or valve prolapsed? Yes or No
18. _____Joint pain or swelling
List Joints: _________________________________________________________
19. _____Stiffness of the joints, neck or back
20. _____Muscle pain or cramps
21. _____Twitching of the face or other muscles
22. _____Headaches
23. _____Neck cracks; 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. _____Lightheadedness, wooziness, poor balance, difficulty walking
30. _____Tremor
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 or too little or early awakening
38. _____Exaggerated symptoms or worse hangover from alcohol
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