Lyme - Tick Borne Disease - Initial Symptom Check List Page 2
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4MULTI-CHRONIC INFECTIOUS DISEASE SYNDROM
POTENTIAL PATIENT QUESTIONAIRE
Name: _____________________________________
Date: ____________ Age: ______
1. Where do you live? City:_________________________ State:________________
2. How long have you been sick? (circle)
<1 yr
1-2 yrs
3-5 yrs
6-10 yrs >10 yrs (__)
a. Have you been continuously ill (______) or have had periods of recovery and relapse?
(____) (check whichever applies)
b. Rate your overall health status including level of pain, fatigue, neurologic or other symptoms
by circling the number that applies:
(severely ill) 1
2
3
4
5
6
7
8
9
10 (healthy)
3. What is your status (check one)
a. ____ Working full time at an office
b. ____ Working part time at an office
c. ____ Working full time at home
d. ____ Working part time at home
e. ____ Not working due to health problems
f. ____ Not working for other reasons
g. ____ Have you been declared disabled and are receiving any disability services (insurance,
financial support, etc.)
4. What infections have you been either diagnosed with or are suspected based on clinical symptoms?
Check all that apply:
a. _____ Borrelia (Lyme Disease)
b. _____ Bartonella
c. _____ Babesia - any specific species? ________________
d. _____ Other bacteria? _____________________________
e. _____ Mycoplasma
f. _____ Viruses - any specific species? ________________
g. _____ Parasites - any specific species? ________________
h. _____ Fungi and Yeast (Candida and other species)
i. _____ Other _____________________________________
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